MEDICARE: KYLIE IMMETHUN GAUSTAD NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	53-76912-101	KS

General Provider Information

NPI Number	:	1487022471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLIE IMMETHUN GAUSTAD NP-C

Provider Business Mailing Address
First Line	:	3801 DR MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64130-2807
Country	:	US
Telephone Number	:	816-923-5800
Fax Number	:	816-922-1070

Provider Business Practice Location Address
First Line	:	6013 LEAVENWORTH RD
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66104-1436
Country	:	US
Telephone Number	:	913-321-2200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2015
Last Update Date	:	03/19/2026

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