Healthcare Provider Details

I. General information

NPI: 1679281216
Provider Name (Legal Business Name): VIRGINIA BRAVO-SAMPAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIRGINIA BRAVO-MORELOS

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 HOLMES ST
KANSAS CITY MO
64108-2640
US

IV. Provider business mailing address

1207 BELINDER DR
RAYMORE MO
64083-8372
US

V. Phone/Fax

Practice location:
  • Phone: 913-544-7618
  • Fax:
Mailing address:
  • Phone: 913-544-7618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number2016003575
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: