Provider Demographics
NPI:1528035144
Name:KNICKERBOCKER, PHYLLIS (CRNA)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64802-0760
Mailing Address - Country:US
Mailing Address - Phone:417-624-3040
Mailing Address - Fax:316-652-0340
Practice Address - Street 1:2727 MCCLELLAND BLVD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1626
Practice Address - Country:US
Practice Address - Phone:417-781-2727
Practice Address - Fax:316-652-0340
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999137827367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO108602AOtherBCBS
P00189203Medicare ID - Type UnspecifiedRAILROAD MEDICARE