Healthcare Provider Details

I. General information

NPI: 1699293084
Provider Name (Legal Business Name): LARA LENEA KALJUMAA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 09/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N AMIDON AVE STE 210
WICHITA KS
67203-2137
US

IV. Provider business mailing address

1900 N AMIDON AVE STE 210
WICHITA KS
67203-2137
US

V. Phone/Fax

Practice location:
  • Phone: 316-260-4110
  • Fax:
Mailing address:
  • Phone: 316-260-4110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number77833
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: