Healthcare Provider Details

I. General information

NPI: 1912989138
Provider Name (Legal Business Name): DANE K WICKS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SW LONGVIEW BLVD STE 280
LEES SUMMIT MO
64081-2157
US

IV. Provider business mailing address

5750 JOHNSTON ST STE 205
LAFAYETTE LA
70503-5345
US

V. Phone/Fax

Practice location:
  • Phone: 337-991-9276
  • Fax:
Mailing address:
  • Phone: 337-991-9276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number84-288
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number84-288
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR4C66
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: