Healthcare Provider Details

I. General information

NPI: 1871754374
Provider Name (Legal Business Name): JENNIFER DIANE ELLZEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 GILLHAM RD
KANSAS CITY MO
64108-4619
US

IV. Provider business mailing address

2401 GILLHAM RD ATTN PROVIDER ENROLLMENT DEPT
KANSAS CITY MO
64108-4619
US

V. Phone/Fax

Practice location:
  • Phone: 816-234-3000
  • Fax:
Mailing address:
  • Phone: 816-701-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080B0002X
TaxonomyPediatric Obesity Medicine Physician
License Number04-52890
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2080B0002X
TaxonomyPediatric Obesity Medicine Physician
License Number2026025741
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: