MEDICARE: MRS. KRISTINE D MALL RN BC ANP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	127507	MO

General Provider Information

NPI Number	:	1659453546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRISTINE D MALL RN BC ANP

Provider Business Mailing Address
First Line	:	2409 SW CURRENT LN
Second Line	:
City	:	LEES SUMMIT
State	:	MO
Zip	:	64082-4099
Country	:	US
Telephone Number	:	816-524-5432
Fax Number	:

Provider Business Practice Location Address
First Line	:	2330 E MEYER BLVD STE 101
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64132-1140
Country	:	US
Telephone Number	:	816-276-9800
Fax Number	:	816-276-9201

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	02/11/2022

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