Provider Demographics
NPI:1740262278
Name:ENTLICHER-STEWART, RONDA S (APRN,BC)
Entity type:Individual
Prefix:
First Name:RONDA
Middle Name:S
Last Name:ENTLICHER-STEWART
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 N BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3016
Mailing Address - Country:US
Mailing Address - Phone:417-326-6021
Mailing Address - Fax:417-326-6347
Practice Address - Street 1:1240 N BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3016
Practice Address - Country:US
Practice Address - Phone:417-326-6021
Practice Address - Fax:417-326-6347
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO143238363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP34621Medicare UPIN