Healthcare Provider Details

I. General information

NPI: 1285564799
Provider Name (Legal Business Name): COURTNEY MICHELLE BOHANNAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 N HILLSIDE ST STE 510
WICHITA KS
67214-4928
US

IV. Provider business mailing address

551 N HILLSIDE ST STE 510
WICHITA KS
67214-4928
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-0559
  • Fax: 316-685-0455
Mailing address:
  • Phone: 316-685-0559
  • Fax: 316-685-0455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number53-85832-012
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number13-117282-012
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: