Healthcare Provider Details

I. General information

NPI: 1598102204
Provider Name (Legal Business Name): NICKA KHALILOVA N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NW R D MIZE RD STE 206
BLUE SPRINGS MO
64014-2513
US

IV. Provider business mailing address

4401 WORNALL RD
KANSAS CITY MO
64111-3241
US

V. Phone/Fax

Practice location:
  • Phone: 816-655-5403
  • Fax: 816-655-5257
Mailing address:
  • Phone: 816-932-0340
  • Fax: 816-932-3148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number75966
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2013015317
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704312135
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number75966
License Number StateKS
# 5
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2013015317
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2013015317
License Number StateMO
# 7
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number75966
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: