Healthcare Provider Details

I. General information

NPI: 1609490341
Provider Name (Legal Business Name): KIMBERLY KAYE STEVENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1914 NW COPPER OAKS CIR
BLUE SPRINGS MO
64015-8300
US

IV. Provider business mailing address

1914 NW COPPER OAKS CIR
BLUE SPRINGS MO
64015-8300
US

V. Phone/Fax

Practice location:
  • Phone: 816-330-5039
  • Fax: 816-988-4910
Mailing address:
  • Phone: 816-330-5039
  • Fax: 816-988-4910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: