Provider Demographics
NPI:1003802406
Name:GANN, BEVERLY JO (RNC,WHNP)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JO
Last Name:GANN
Suffix:
Gender:F
Credentials:RNC,WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4360 STATE HIGHWAY 176 E
Mailing Address - Street 2:
Mailing Address - City:CHESTNUTRIDGE
Mailing Address - State:MO
Mailing Address - Zip Code:65630-3021
Mailing Address - Country:US
Mailing Address - Phone:417-443-0039
Mailing Address - Fax:
Practice Address - Street 1:2828 N NATIONAL AVE
Practice Address - Street 2:DOCTORS HOSPITAL OF SPRINGFIELD, SPECIALTY CLINIC
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-4306
Practice Address - Country:US
Practice Address - Phone:417-837-4000
Practice Address - Fax:417-875-4724
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORN 091078363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00314636OtherRR MEDICARE
MO1003802406Medicaid
MO425443736Medicaid
MO824970115Medicare PIN
P00314636OtherRR MEDICARE
MO1003802406Medicaid