Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | 2016000625 | MO |
NPI | 1053778787 |
---|---|
Provider Name | Kelly Bush |
First Address | Kansas City, MO 64131 |
Second Address | Kansas City, MO 64111-3498 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/01/2016 |
Last Update Date | 15/11/2017 |