Healthcare Provider Details

I. General information

NPI: 1053778787
Provider Name (Legal Business Name): KELLY BUSH APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 BROADWAY SUITE 520
KANSAS CITY MO
64111-3498
US

IV. Provider business mailing address

901 E 104TH ST MAILSTOP 400
KANSAS CITY MO
64131
US

V. Phone/Fax

Practice location:
  • Phone: 816-531-4080
  • Fax: 816-531-0281
Mailing address:
  • Phone: 816-599-9499
  • Fax: 816-932-9670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2016000625
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: