Basic Information
| Provider Information | |||||||||
| NPI: | 1831787688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYBLE | ||||||||
| FirstName: | AUDRA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2305 GEORGIA ST | ||||||||
| Address2: | |||||||||
| City: | LOUISIANA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633532559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737545531 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1420 S BUSINESS 61 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633345230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733245562 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2021 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2021000399 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.