Basic Information
Provider Information | |||||||||
NPI: | 1790452225 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THILL | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SPENCER | ||||||||
OtherFirstName: | ANGELA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 246 WHISPERING COVE DRIVE | ||||||||
Address2: |   | ||||||||
City: | CAMDENTON | ||||||||
State: | MO | ||||||||
PostalCode: | 65020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5157085204 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 156 MISSOURI BLVD | ||||||||
Address2: |   | ||||||||
City: | GRAVOIS MILLS | ||||||||
State: | MO | ||||||||
PostalCode: | 650375394 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5733745263 | ||||||||
FaxNumber: | 5733744933 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2021 | ||||||||
LastUpdateDate: | 08/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2021029996 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.