Provider Demographics
NPI:1538321906
Name:WOMBOLD, BEVERLY D (FNP)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:D
Last Name:WOMBOLD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 ARDUSER DR
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:MO
Mailing Address - Zip Code:64773
Mailing Address - Country:US
Mailing Address - Phone:417-646-8159
Mailing Address - Fax:471-646-8379
Practice Address - Street 1:855 ARDUSER DR
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:MO
Practice Address - Zip Code:64776-6278
Practice Address - Country:US
Practice Address - Phone:417-646-8153
Practice Address - Fax:471-646-8379
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO095597363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner