=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093279945
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA A KNEISLY NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2019
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19550 E 39TH ST S STE 310
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64057-2306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-478-8113
-----------------------------------------------------
Fax | 816-478-8108
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19550 E 39TH ST S
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64057-2358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-478-8113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 2019001504
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------