Provider Demographics
NPI:1275960254
Name:HARRELL, DEBORAH ANN (MSN,APRN FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:ANN
Last Name:HARRELL
Suffix:
Gender:F
Credentials:MSN,APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CREEKSIDE OFFICE DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3289
Mailing Address - Country:US
Mailing Address - Phone:636-639-6262
Mailing Address - Fax:
Practice Address - Street 1:105 CREEKSIDE OFFICE DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3289
Practice Address - Country:US
Practice Address - Phone:636-639-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013030779163W00000X
MOF0813261363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1275960254Medicaid
MO1275960254Medicaid
MOMA4982008Medicare PIN