Provider Demographics
NPI:1619086816
Name:HARTER, PHYLLIS JEAN (FNP)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:JEAN
Last Name:HARTER
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 5681
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-5681
Mailing Address - Country:US
Mailing Address - Phone:417-831-0150
Mailing Address - Fax:417-831-0155
Practice Address - Street 1:440 E TAMPA ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-1131
Practice Address - Country:US
Practice Address - Phone:417-831-0150
Practice Address - Fax:417-831-0155
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO063773363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424657633Medicaid
MO827343959Medicare ID - Type UnspecifiedMEDICARE