Healthcare Provider Details

I. General information

NPI: 1932012192
Provider Name (Legal Business Name): STACEY KASSANCHUK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 S PELHAM PATH
RAYMORE MO
64083-8140
US

IV. Provider business mailing address

502 S PELHAM PATH
RAYMORE MO
64083-8140
US

V. Phone/Fax

Practice location:
  • Phone: 913-636-6417
  • Fax:
Mailing address:
  • Phone: 913-636-6417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: