Healthcare Provider Details

I. General information

NPI: 1407410210
Provider Name (Legal Business Name): MALLORY EUBANK MSN, APRN-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 04/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 SE BLUE PKWY
LEES SUMMIT MO
64063-1007
US

IV. Provider business mailing address

9022 NE 103RD TER
KANSAS CITY MO
64157-7872
US

V. Phone/Fax

Practice location:
  • Phone: 816-282-5000
  • Fax:
Mailing address:
  • Phone: 816-560-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018043924
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: