Provider Demographics
NPI:1790037885
Name:DEBORD, HATTIE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:HATTIE
Middle Name:
Last Name:DEBORD
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 1:12 JEFFERSON SQ
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-1031
Mailing Address - Country:US
Mailing Address - Phone:636-586-6685
Mailing Address - Fax:636-586-2780
Practice Address - Street 1:12 JEFFERSON SQ
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-1031
Practice Address - Country:US
Practice Address - Phone:636-586-6685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022029288363LP0808X
MO2012033866363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health