Provider Demographics
NPI:1619394236
Name:BAKER, BECKY
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 E SOUTH HILLS DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2659
Mailing Address - Country:US
Mailing Address - Phone:660-562-2600
Mailing Address - Fax:660-562-7911
Practice Address - Street 1:2016 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2655
Practice Address - Country:US
Practice Address - Phone:660-562-2600
Practice Address - Fax:660-562-7911
Is Sole Proprietor?:No
Enumeration Date:2014-03-20
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA079775363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA079775OtherLICENSE