Healthcare Provider Details

I. General information

NPI: 1295775138
Provider Name (Legal Business Name): BOB BORN APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 E 2ND ST N
WICHITA KS
67214-4119
US

IV. Provider business mailing address

1421 E 2ND ST N
WICHITA KS
67214-4119
US

V. Phone/Fax

Practice location:
  • Phone: 316-303-0333
  • Fax: 316-847-7093
Mailing address:
  • Phone: 316-303-0333
  • Fax: 316-847-7093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number14-78962-091
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number74595
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: