Provider Demographics
NPI:1972593465
Name:STINNETT, AMY KELLAMS (FNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KELLAMS
Last Name:STINNETT
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 1:204 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63873-1402
Mailing Address - Country:US
Mailing Address - Phone:573-379-5467
Mailing Address - Fax:573-379-5671
Practice Address - Street 1:204 E 3RD ST
Practice Address - Street 2:
Practice Address - City:PORTAGEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63873-1402
Practice Address - Country:US
Practice Address - Phone:573-379-5467
Practice Address - Fax:573-379-5671
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001008920363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO42928806Medicaid
MO000081941Medicare ID - Type Unspecified
MO42928806Medicaid