Provider Demographics
NPI:1386047025
Name:WITHAM, BECKY LYNN (FNP-C)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:LYNN
Last Name:WITHAM
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:LYNN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1050 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2905
Mailing Address - Country:US
Mailing Address - Phone:855-406-3324
Mailing Address - Fax:573-458-8363
Practice Address - Street 1:1060 W 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2905
Practice Address - Country:US
Practice Address - Phone:855-406-3324
Practice Address - Fax:573-458-8363
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014035055363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1386047025Medicaid
MO132300544Medicare PIN