1679757116 NPI number — SUE ELLEN BREESE ANP-BC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679757116 NPI number — SUE ELLEN BREESE ANP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREESE
Provider First Name:
SUE
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAY
Provider Other First Name:
SUE
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679757116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5950 N OAK TRFY STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64118-5164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-268-8501
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5950 N. OAK TRFY
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64118-5164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-268-8501
Provider Business Practice Location Address Fax Number:
816-452-5700
Provider Enumeration Date:
12/19/2007

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: 163W00000X , with the licence number:  14-97852-042 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163W00000X , with the licence number: 2001005022 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 53-46184-042 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 2001005022 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 2001005022 , 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: 1679757116 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200633510B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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