Basic Information
| Provider Information | |||||||||
| NPI: | 1760739668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASSA | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STRODER | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | HC 1 BOX 77A | ||||||||
| Address2: | |||||||||
| City: | LEOPOLD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637609714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732382542 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 545 BROADRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637553001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732438408 | ||||||||
| FaxNumber: | 5732430445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2012 | ||||||||
| LastUpdateDate: | 08/09/2012 | ||||||||
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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 | 163W00000X | 2004018094 | MO | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 2012025816 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.