Healthcare Provider Details

I. General information

NPI: 1417915935
Provider Name (Legal Business Name): KRISTIN LEIGH HAM OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 ENSIGN HILL DR SUITE F
PLATTE CITY MO
64079-7836
US

IV. Provider business mailing address

2716 N 25TH ST
OZARK MO
65721-9130
US

V. Phone/Fax

Practice location:
  • Phone: 816-431-2202
  • Fax: 816-431-2205
Mailing address:
  • Phone: 309-369-7486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009634
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1594
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2001016965
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: