Healthcare Provider Details

I. General information

NPI: 1457307654
Provider Name (Legal Business Name): RUTH POTTINGER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16225 GILMAN RD.
LEAVENWORTH KS
66048
US

IV. Provider business mailing address

10217 STONEHAUS DR
LEES SUMMIT MO
64086-9613
US

V. Phone/Fax

Practice location:
  • Phone: 913-727-5600
  • Fax: 913-727-5602
Mailing address:
  • Phone: 816-554-3620
  • Fax: 816-524-4218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number54594
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number103014
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: