Healthcare Provider Details

I. General information

NPI: 1609117555
Provider Name (Legal Business Name): SAMANTHA ANNETTE FIKRU FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 SHAWNEE MISSION PKWY STE 1200
FAIRWAY KS
66205-2528
US

IV. Provider business mailing address

888 W BONNEVILLE AVE
LAS VEGAS NV
89106-0100
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-0555
  • Fax: 913-945-5035
Mailing address:
  • Phone: 702-483-6011
  • Fax: 702-483-6028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberTAPN700890
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number53-78303-102
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: