Basic Information
| Provider Information | |||||||||
| NPI: | 1356379978 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLSAP | ||||||||
| FirstName: | ELEANOR | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6120 SHADYBROOK ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672081862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162695000 | ||||||||
| FaxNumber: | 3162690404 | ||||||||
| Practice Location | |||||||||
| Address1: | 1315 N WEST ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672031382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169431295 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 04/15/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 44970 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200381990A | 05 | KS | MEDICAID | P00353059 | 01 | RAIL ROAD MEDICARE | OTHER | 161720 | 01 | KS | BLUECROSS BLUESHIELD KS | OTHER |