Healthcare Provider Details

I. General information

NPI: 1124727771
Provider Name (Legal Business Name): BRENDA LYNNETTE BASGALL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2023
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 E KELLOGG DR
WICHITA KS
67218-1607
US

IV. Provider business mailing address

5117 N NEWTON CIR
PARK CITY KS
67219-2830
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-2221
  • Fax:
Mailing address:
  • Phone: 316-869-7113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number73154
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: