Basic Information
Provider Information | |||||||||
NPI: | 1003128596 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GADDY | ||||||||
FirstName: | MARILYN | ||||||||
MiddleName: | GAY | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | R.N. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1800 COMMUNITY DRIVE | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MO | ||||||||
PostalCode: | 64735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6608858131 | ||||||||
FaxNumber: | 6608853690 | ||||||||
Practice Location | |||||||||
Address1: | 205 E DAKOTA | ||||||||
Address2: |   | ||||||||
City: | BUTLER | ||||||||
State: | MO | ||||||||
PostalCode: | 64730 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6606794636 | ||||||||
FaxNumber: | 6606764310 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2010 | ||||||||
LastUpdateDate: | 07/13/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | RN138954 | MO | Y |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.