Basic Information
| Provider Information | |||||||||
| NPI: | 1386047025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BECKY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | BECKY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | FNP-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1050 W 10TH STREET | ||||||||
| Address2: | ATTN: EXECUTIVE DIRECTOR OF PHYSICIAN CLINICS | ||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733649000 | ||||||||
| FaxNumber: | 5734262108 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 W 10TH STREET | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734583324 | ||||||||
| FaxNumber: | 5734588445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2014 | ||||||||
| LastUpdateDate: | 07/29/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2014035055 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1386047025 | 05 | MO | MEDICAID |