Provider Demographics
NPI:1194291054
Name:LALLATHIN, AMY (NP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LALLATHIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:448 STATE HIGHWAY 248 STE 120
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-3725
Mailing Address - Country:US
Mailing Address - Phone:417-337-5000
Mailing Address - Fax:
Practice Address - Street 1:448 STATE HIGHWAY 248 STE 120
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-3725
Practice Address - Country:US
Practice Address - Phone:417-337-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014002993163W00000X
MO2018040401363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse