Healthcare Provider Details

I. General information

NPI: 1912575531
Provider Name (Legal Business Name): TREY KYLE FORWARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 VILLAGE DR
SAINT JOSEPH MO
64506-4954
US

IV. Provider business mailing address

2303 VILLAGE DR
SAINT JOSEPH MO
64506-4954
US

V. Phone/Fax

Practice location:
  • Phone: 816-000-1486
  • Fax:
Mailing address:
  • Phone: 816-307-8231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021019739
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: