=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619708633
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON DALE BURCHETT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2024
-----------------------------------------------------
Last Update Date | 09/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1950 DIAMOND PKWY
-----------------------------------------------------
City | NORTH KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64116-4328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-842-6717
-----------------------------------------------------
Fax | 816-842-2574
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2529 GLENN HENDREN DR STE 202
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-9602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-781-8400
-----------------------------------------------------
Fax | 816-781-8263
-----------------------------------------------------
=====================================================
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 | 2024009618
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------