Healthcare Provider Details

I. General information

NPI: 1578190062
Provider Name (Legal Business Name): IMMACULATE KUME NGUM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8219 E 85TH TER
RAYTOWN MO
64138-3020
US

IV. Provider business mailing address

8219 E 85TH TER
RAYTOWN MO
64138-3020
US

V. Phone/Fax

Practice location:
  • Phone: 816-204-1334
  • Fax:
Mailing address:
  • Phone: 816-204-1334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number23541795
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number80845
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: