Provider Demographics
NPI:1588373948
Name:MIRLY, STEPHANIE M (FNP, ENP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:MIRLY
Suffix:
Gender:F
Credentials:FNP, ENP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:M
Other - Last Name:WILKINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:211 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5049
Practice Address - Country:US
Practice Address - Phone:573-331-5110
Practice Address - Fax:573-335-4689
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022007152363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner