Healthcare Provider Details

I. General information

NPI: 1063539823
Provider Name (Legal Business Name): SYREETA LYNN VAN ROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SYREETA LYNN DICKERSON

II. Dates (important events)

Enumeration Date: 03/24/2007
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16659 E 23RD ST S
INDEPENDENCE MO
64055-1922
US

IV. Provider business mailing address

PO BOX 740019
ATLANTA GA
30374-0019
US

V. Phone/Fax

Practice location:
  • Phone: 816-631-1885
  • Fax:
Mailing address:
  • Phone: 773-644-3941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015039584
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number2015039584
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number77550-072
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number200380880A
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: