Basic Information
| Provider Information | |||||||||
| NPI: | 1528384823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | D'AGOSTINO | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOTMER | ||||||||
| OtherFirstName: | MANDY | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2230 S SPRINGFIELD AVE | ||||||||
| Address2: | STE H | ||||||||
| City: | BOLIVAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656139133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177774800 | ||||||||
| FaxNumber: | 4173267300 | ||||||||
| Practice Location | |||||||||
| Address1: | 2230 S SPRINGFIELD AVE | ||||||||
| Address2: | STE H | ||||||||
| City: | BOLIVAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656139133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177774800 | ||||||||
| FaxNumber: | 4173267300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2010 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 20030009032 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.