Provider Demographics
NPI:1154792810
Name:ZIMMER, FAWN (FNP)
Entity type:Individual
Prefix:MRS
First Name:FAWN
Middle Name:
Last Name:ZIMMER
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 1:819 S BUSINESS HIGHWAY 13
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:64067-1515
Mailing Address - Country:US
Mailing Address - Phone:816-330-6426
Mailing Address - Fax:660-259-2440
Practice Address - Street 1:206 N BISMARK ST STE A
Practice Address - Street 2:
Practice Address - City:CONCORDIA
Practice Address - State:MO
Practice Address - Zip Code:64020-8101
Practice Address - Country:US
Practice Address - Phone:877-344-3572
Practice Address - Fax:866-228-4492
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8647363LF0000X
MO2015035378363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420026294Medicaid
AZ138235Medicaid