Provider Demographics
NPI:1629049929
Name:WAHWASSUCK, JOSETTA ELIESE (MSN, FNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:JOSETTA
Middle Name:ELIESE
Last Name:WAHWASSUCK
Suffix:
Gender:F
Credentials:MSN, FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:206 S MILL ST
Practice Address - Street 2:
Practice Address - City:ELDON
Practice Address - State:MO
Practice Address - Zip Code:65026-1864
Practice Address - Country:US
Practice Address - Phone:888-403-1071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO096721363LF0000X, 363LP0808X
KS44870363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
29929044OtherBLUE CROSS BLUE SHIELD
P00430963OtherRAILROAD MEDICARE
MO423989722Medicaid
29929044OtherBLUE CROSS BLUE SHIELD
P00430963OtherRAILROAD MEDICARE