=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558721837
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INFANT EAR SHAPING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2016
-----------------------------------------------------
Last Update Date | 03/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4545 N RUSHWOOD CT
-----------------------------------------------------
City | BEL AIRE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67226-1478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-573-9228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4545 N RUSHWOOD CT
-----------------------------------------------------
City | BEL AIRE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67226-1478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-573-9228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JENNIFER SEBES
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 316-573-9228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------