Healthcare Provider Details

I. General information

NPI: 1013763382
Provider Name (Legal Business Name): KJK WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2024
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N MUR LEN RD STE 104B
OLATHE KS
66062-1794
US

IV. Provider business mailing address

801 N MUR LEN RD STE 104B
OLATHE KS
66062-1794
US

V. Phone/Fax

Practice location:
  • Phone: 913-207-5089
  • Fax: 913-273-1094
Mailing address:
  • Phone: 913-207-5089
  • Fax: 913-273-1094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KRISTY M PROVENCE
Title or Position: OWNE/NURSE PRACTITIONER
Credential: APRN-C
Phone: 913-207-5089