1487708004 NPI number — SYBLE JEAN CRETZMEYER NP

Table of content: SYBLE JEAN CRETZMEYER NP (NPI 1487708004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487708004 NPI number — SYBLE JEAN CRETZMEYER NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRETZMEYER
Provider First Name:
SYBLE
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487708004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19550 E. 39TH ST.
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
INDEPENDENCE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64057-1855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-478-0220
Provider Business Mailing Address Fax Number:
816-795-3484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19550 E. 39TH ST.
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64057-1855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-478-0220
Provider Business Practice Location Address Fax Number:
816-795-3484
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  113738 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LW0102X , with the licence number: 113738 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 429676307 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com