Provider Demographics
NPI:1134206873
Name:DETLEFSEN, ROBERT W (ARNP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:DETLEFSEN
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 COUNTY ROAD 306
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-5436
Mailing Address - Country:US
Mailing Address - Phone:573-581-1196
Mailing Address - Fax:573-581-1981
Practice Address - Street 1:455 N MCKENZIE LN
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-8901
Practice Address - Country:US
Practice Address - Phone:319-471-2479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG-115825363LP0808X
KS75810363LP0808X
MO2013003487363LP0808X
IAG115825363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health