Healthcare Provider Details

I. General information

NPI: 1336510312
Provider Name (Legal Business Name): STACEY KALE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2015
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 EAST ST
IOLA KS
66749-4402
US

IV. Provider business mailing address

1408 EAST ST
IOLA KS
66749-4402
US

V. Phone/Fax

Practice location:
  • Phone: 620-365-3115
  • Fax: 620-365-7717
Mailing address:
  • Phone: 620-365-3115
  • Fax: 620-365-7717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-76889-072
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: