Provider Demographics
NPI:1427240548
Name:MCEACHERN, AGATHE (FNP)
Entity type:Individual
Prefix:
First Name:AGATHE
Middle Name:
Last Name:MCEACHERN
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:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402-0579
Mailing Address - Country:US
Mailing Address - Phone:573-774-2715
Mailing Address - Fax:
Practice Address - Street 1:107 ICHORD AVE
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-5401
Practice Address - Country:US
Practice Address - Phone:573-774-2715
Practice Address - Fax:573-774-2792
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO153033163WD0400X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
153033OtherLICENSE
MO000015401Medicare PIN