Provider Demographics
NPI:1629599873
Name:FAST, BETHANY K (FNP-C, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:K
Last Name:FAST
Suffix:
Gender:F
Credentials:FNP-C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 DEER RUN DR
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-4303
Mailing Address - Country:US
Mailing Address - Phone:417-321-4233
Mailing Address - Fax:417-667-9216
Practice Address - Street 1:815 S ASH ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-3222
Practice Address - Country:US
Practice Address - Phone:417-667-8352
Practice Address - Fax:417-667-9216
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019027475363LP0808X
MO2017021753363LF0000X
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
MO1629599873Medicaid