Healthcare Provider Details

I. General information

NPI: 1861049215
Provider Name (Legal Business Name): GLORY I. CHUKWUSOM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6530 TROOST AVE STE A
KANSAS CITY MO
64131-1301
US

IV. Provider business mailing address

6530 TROOST AVE STE A
KANSAS CITY MO
64131-1301
US

V. Phone/Fax

Practice location:
  • Phone: 816-361-0670
  • Fax: 816-444-6936
Mailing address:
  • Phone: 816-361-0670
  • Fax: 816-444-6936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2019020223
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: