Provider Demographics
NPI:1790393049
Name:FORSON, KATHY (FNP-C)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:FORSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:MCCULLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1109 E. LINWOOD DR.
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-1851
Mailing Address - Country:US
Mailing Address - Phone:417-830-6134
Mailing Address - Fax:
Practice Address - Street 1:1235 E. CHEROKEE ST.
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-820-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOF12190784363LF0000X
MO2020006141363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily