Healthcare Provider Details

I. General information

NPI: 1144136664
Provider Name (Legal Business Name): TRACEY MAMEROW APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10950 W 86TH ST
LENEXA KS
66214-1634
US

IV. Provider business mailing address

10950 W 86TH ST
LENEXA KS
66214-1634
US

V. Phone/Fax

Practice location:
  • Phone: 913-722-4240
  • Fax: 913-721-0298
Mailing address:
  • Phone: 913-722-4240
  • Fax: 913-721-0298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5386123032
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2026035189
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: