Provider Demographics
NPI:1427610377
Name:ETCHESON, REILLY LUCILLE (DNP, APRN-CNP, FNP)
Entity type:Individual
Prefix:DR
First Name:REILLY
Middle Name:LUCILLE
Last Name:ETCHESON
Suffix:
Gender:F
Credentials:DNP, APRN-CNP, 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 2009
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-2009
Mailing Address - Country:US
Mailing Address - Phone:417-206-9300
Mailing Address - Fax:417-206-9306
Practice Address - Street 1:3130 WISCONSIN AVE STE 6
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-2800
Practice Address - Country:US
Practice Address - Phone:417-206-9300
Practice Address - Fax:417-209-9306
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019021621363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner