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General NPI Number Information
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NPI Number | 1962226126
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Entity Type | Individual
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Provider Name | SHALEY KNICKERBOCKER
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Gender | Female
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Dates
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Enumeration Date | 11/13/2024
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Last Update Date | 11/13/2024
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Provider Practice Location Address
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Address Line | 9100 W 74TH ST
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City | SHAWNEE MISSION
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State | KS
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Zip | 66204-4004
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Country | US
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Telephone | 913-676-7400
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Fax |
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Provider Business Mailing Address
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Address Line | 514 FLAME WAY
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City | BALDWIN CITY
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State | KS
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Zip | 66006-4168
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Country | US
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Telephone | 785-443-0834
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WE0003X
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Taxonomy Name | Emergency Registered Nurse
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License Number | 138424
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License Number State | KS
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