Provider Demographics
NPI:1265753792
Name:FORSYTH FAMILY MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:FORSYTH FAMILY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:WYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:417-546-2590
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:MO
Mailing Address - Zip Code:65653-1239
Mailing Address - Country:US
Mailing Address - Phone:417-546-2590
Mailing Address - Fax:417-546-2594
Practice Address - Street 1:10726 E HWY 76
Practice Address - Street 2:STE. G
Practice Address - City:FORSYTH
Practice Address - State:MO
Practice Address - Zip Code:65653
Practice Address - Country:US
Practice Address - Phone:417-546-2590
Practice Address - Fax:417-546-2594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-18
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO120158363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty