Basic Information
| Provider Information | |||||||||
| NPI: | 1447505862 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODFORD | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | RHEA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RHEA | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3810 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648033810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173474662 | ||||||||
| FaxNumber: | 4173479453 | ||||||||
| Practice Location | |||||||||
| Address1: | 3415 MCINTOSH CIR | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648043651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173474000 | ||||||||
| FaxNumber: | 4173474064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2012 | ||||||||
| LastUpdateDate: | 09/06/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2018043161 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.