Basic Information
| Provider Information | |||||||||
| NPI: | 1235165721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEVOE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3810 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648033810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173478688 | ||||||||
| FaxNumber: | 4173478693 | ||||||||
| Practice Location | |||||||||
| Address1: | 3202 MCINTOSH CIR | ||||||||
| Address2: | STE 102 | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648043646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173478688 | ||||||||
| FaxNumber: | 4173478693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 05/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 129116 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 500019747 | 01 | RR MEDICARE | OTHER | 118126 | 01 | MO | ANTHEM | OTHER | 100023320A | 05 | OK | MEDICAID | 100335980A | 05 | KS | MEDICAID | 423962208 | 05 | MO | MEDICAID |