Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 2015039584 | MO |
N | 363LP2300X | Nurse Practitioner - Primary Care | 2015039584 | MO |
N | 363LP2300X | Nurse Practitioner - Primary Care | 77550-072 | KS |
NPI | 1063539823 |
---|---|
Provider Name | Syreeta Lynn Van Ross |
First Address | Kansas City, MO 64114-4673 |
Second Address | Kansas City, MO 64114-4673 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2007 |
Last Update Date | 07/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200380880A | (05) | KS |