Healthcare Provider Details

I. General information

NPI: 1720586621
Provider Name (Legal Business Name): TRACE ROBERT YULE PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 S ELIZABETH ST
INDEPENDENCE MO
64057-1759
US

IV. Provider business mailing address

109 W 27TH ST RM 5S
NEW YORK NY
10001-6208
US

V. Phone/Fax

Practice location:
  • Phone: 816-768-0090
  • Fax:
Mailing address:
  • Phone: 833-351-8255
  • Fax: 888-815-3583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2018001607
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: