Provider Demographics
NPI:1063968089
Name:GUILLORY, JA ANNA D (FNP)
Entity type:Individual
Prefix:
First Name:JA ANNA
Middle Name:D
Last Name:GUILLORY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3183 W MELBOURNE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2263
Mailing Address - Country:US
Mailing Address - Phone:417-592-4538
Mailing Address - Fax:
Practice Address - Street 1:444 W FORT ST FL 2
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4535
Practice Address - Country:US
Practice Address - Phone:208-422-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016032668363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily