Basic Information
Provider Information | |||||||||
NPI: | 1457881716 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NIMMO | ||||||||
FirstName: | STEPHANIE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 118 W DALLAS ST | ||||||||
Address2: |   | ||||||||
City: | BUFFALO | ||||||||
State: | MO | ||||||||
PostalCode: | 656228669 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8554207900 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 118 W DALLAS ST | ||||||||
Address2: |   | ||||||||
City: | BUFFALO | ||||||||
State: | MO | ||||||||
PostalCode: | 656228669 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4173456101 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2017 | ||||||||
LastUpdateDate: | 07/14/2017 | ||||||||
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 | 163W00000X | 2005006620 | MO | N |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | 2017023153 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | PENDING | 01 | MO | MEDICARE | OTHER | PENDING | 05 | MO |   | MEDICAID |