Healthcare Provider Details

I. General information

NPI: 1710709977
Provider Name (Legal Business Name): CRYSTAL OBIEFUNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 NW BARRY RD
KANSAS CITY MO
64155
US

IV. Provider business mailing address

4524 N 108TH ST
KANSAS CITY KS
66109
US

V. Phone/Fax

Practice location:
  • Phone: 816-413-2500
  • Fax:
Mailing address:
  • Phone: 913-575-9562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number13-152293-122
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: