Basic Information
Provider Information
NPI: 1003802406
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GANN
FirstName: BEVERLY
MiddleName: JO
NamePrefix:  
NameSuffix:  
Credential: RNC,WHNP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4360 STATE HIGHWAY 176 E
Address2:  
City: CHESTNUTRIDGE
State: MO
PostalCode: 656303021
CountryCode: US
TelephoneNumber: 4174430039
FaxNumber:  
Practice Location
Address1: 2828 N NATIONAL AVE
Address2: DOCTORS HOSPITAL OF SPRINGFIELD, SPECIALTY CLINIC
City: SPRINGFIELD
State: MO
PostalCode: 658034306
CountryCode: US
TelephoneNumber: 4178374000
FaxNumber: 4178754724
Other Information
ProviderEnumerationDate: 09/21/2005
LastUpdateDate: 06/16/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LW0102XRN 091078MOY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health

ID Information
IDTypeStateIssuerDescription
42544373605MO MEDICAID
100380240605MO MEDICAID
P0031463601 RR MEDICAREOTHER


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