Healthcare Provider Details

I. General information

NPI: 1275059164
Provider Name (Legal Business Name): JAMIE DERLETH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E 24TH ST
KANSAS CITY MO
64108-2776
US

IV. Provider business mailing address

1000 E 24TH ST
KANSAS CITY MO
64108-2776
US

V. Phone/Fax

Practice location:
  • Phone: 816-965-1156
  • Fax: 816-416-7098
Mailing address:
  • Phone: 816-965-1156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number051655
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: