Basic Information
Provider Information | |||||||||
NPI: | 1417682295 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KRENZ | ||||||||
FirstName: | COREY | ||||||||
MiddleName: | JACOB | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 105 S EAST ST | ||||||||
Address2: |   | ||||||||
City: | CAMERON | ||||||||
State: | MO | ||||||||
PostalCode: | 644291992 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8162449814 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 901 HEARTLAND RD. | ||||||||
Address2: | # 1800, PLAZA 2 | ||||||||
City: | SAINT JOSEPH | ||||||||
State: | MO | ||||||||
PostalCode: | 645066202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8162328877 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2022 | ||||||||
LastUpdateDate: | 07/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2022027784 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.