Healthcare Provider Details

I. General information

NPI: 1134921265
Provider Name (Legal Business Name): MARY SUE KNUDSEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2025
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 N TWYMAN RD
INDEPENDENCE MO
64058-3212
US

IV. Provider business mailing address

3205 N TWYMAN RD
INDEPENDENCE MO
64058-3212
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number143465
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: