Healthcare Provider Details

I. General information

NPI: 1710784251
Provider Name (Legal Business Name): ELANA BUPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 03/03/2025
Certification Date: 03/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 E KELLOGG DR
WICHITA KS
67218-1607
US

IV. Provider business mailing address

1315 S EMPORIA AVE
WICHITA KS
67211-3213
US

V. Phone/Fax

Practice location:
  • Phone: 316-393-2382
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number13-102303-111
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: