Healthcare Provider Details

I. General information

NPI: 1104273317
Provider Name (Legal Business Name): MRS. ANGELIQUE IRENE CARROLL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. ANGELIQUE IRENE DAVIS

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 E 39TH ST S
INDEPENDENCE MO
64057-2301
US

IV. Provider business mailing address

8717 W 110TH ST SUITE 600
OVERLAND PARK KS
66210-2144
US

V. Phone/Fax

Practice location:
  • Phone: 913-428-2900
  • Fax: 913-428-2951
Mailing address:
  • Phone: 913-428-2900
  • Fax: 913-428-2951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2016019530
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: