MEDICARE: KEYANNA DEBOSE PT, DPT

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	225100000X	Physical Therapist	1107197	KS
2	225100000X	Physical Therapist	CP011884T	VA
3	225100000X	Physical Therapist	CP015406T	MD
4	225100000X	Physical Therapist	P21339	NC
5	225100000X	Physical Therapist	CP017326T	MO

General Provider Information

NPI Number	:	1760105845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEYANNA DEBOSE PT, DPT

Provider Business Mailing Address
First Line	:	960 ABBOTT ST
Second Line	:
City	:	HENDERSON
State	:	NC
Zip	:	27536-3023
Country	:	US
Telephone Number	:	913-605-2572
Fax Number	:

Provider Business Practice Location Address
First Line	:	6264 LEWIS DR STE 100
Second Line	:
City	:	PARKVILLE
State	:	MO
Zip	:	64152-3603
Country	:	US
Telephone Number	:	816-587-8001
Fax Number	:

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

Provider Enumeration Date	:	09/22/2022
Last Update Date	:	03/24/2023

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