Healthcare Provider Details

I. General information

NPI: 1740232578
Provider Name (Legal Business Name): AMBER LEA WOLLESEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9229 WARD PKWY STE 380
KANSAS CITY MO
64114-5471
US

IV. Provider business mailing address

901 E 104TH ST
KANSAS CITY MO
64131-4517
US

V. Phone/Fax

Practice location:
  • Phone: 816-319-4785
  • Fax:
Mailing address:
  • Phone: 816-502-8782
  • Fax: 816-932-9670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number2006008025
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: