Provider Demographics
NPI:1992867212
Name:DONNA JEANNE ERISMAN
Entity type:Organization
Organization Name:DONNA JEANNE ERISMAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:ERISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-624-4754
Mailing Address - Street 1:3420 TANA ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-5450
Mailing Address - Country:US
Mailing Address - Phone:417-624-4754
Mailing Address - Fax:
Practice Address - Street 1:3420 TANA ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-5450
Practice Address - Country:US
Practice Address - Phone:417-624-4754
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO$$$$$$$$$OtherSOCIAL SECURITY NUMBER
MO491449606OtherSOCIAL SECURITY NUMBER