Provider Demographics
NPI:1659606713
Name:MCGRUDER, JILL M (APRN,FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:M
Last Name:MCGRUDER
Suffix:
Gender:F
Credentials:APRN,FNP-BC
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:686 LESTER ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-5025
Mailing Address - Country:US
Mailing Address - Phone:573-686-2411
Mailing Address - Fax:573-686-8452
Practice Address - Street 1:686 LESTER ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-5025
Practice Address - Country:US
Practice Address - Phone:573-686-2411
Practice Address - Fax:573-686-8452
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO147615363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1659606713Medicaid