Healthcare Provider Details

I. General information

NPI: 1427054691
Provider Name (Legal Business Name): CRYSTAL ANN WEKENBORG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 E JACKSON BLVD
JACKSON MO
63755-2907
US

IV. Provider business mailing address

PO BOX 801143
KANSAS CITY MO
64180-1143
US

V. Phone/Fax

Practice location:
  • Phone: 573-243-3115
  • Fax: 573-243-4700
Mailing address:
  • Phone: 573-331-5583
  • Fax: 573-331-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number124573
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: