Healthcare Provider Details

I. General information

NPI: 1467042226
Provider Name (Legal Business Name): KELLY ANN DIULLO BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 01/25/2021
Certification Date: 01/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6034 W 102ND TERRACE
OVERLAND PARK KS
66207
US

IV. Provider business mailing address

6034 W 102ND TERRACE
OVERLAND PARK KS
66207
US

V. Phone/Fax

Practice location:
  • Phone: 417-861-4514
  • Fax:
Mailing address:
  • Phone: 417-861-4514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License Number14-141058-021
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: