Healthcare Provider Details

I. General information

NPI: 1740645001
Provider Name (Legal Business Name): SARAH SUPIRAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15319 W 95TH ST
LENEXA KS
66219-1262
US

IV. Provider business mailing address

15319 W 95TH ST
LENEXA KS
66219-1262
US

V. Phone/Fax

Practice location:
  • Phone: 913-495-9905
  • Fax:
Mailing address:
  • Phone: 913-495-9905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015042086
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5376931041
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: