Healthcare Provider Details

I. General information

NPI: 1780420083
Provider Name (Legal Business Name): RYANN BLACKA APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2024
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15512 W 113TH ST
LENEXA KS
66219-5100
US

IV. Provider business mailing address

1248 SE WARREN DR
LEES SUMMIT MO
64081-2144
US

V. Phone/Fax

Practice location:
  • Phone: 816-861-4700
  • Fax:
Mailing address:
  • Phone: 267-625-7397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-83388-122
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2024007929
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2024007929
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: