Basic Information
| Provider Information | |||||||||
| NPI: | 1487022471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAUSTAD | ||||||||
| FirstName: | KYLIE | ||||||||
| MiddleName: | IMMETHUN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IMMETHUN | ||||||||
| OtherFirstName: | KYLIE | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6013 LEAVENWORTH RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661041436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165995111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6013 LEAVENWORTH RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661041436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133212200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2015 | ||||||||
| LastUpdateDate: | 10/13/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 111908-101 | KS | N | Nursing Service Providers | Registered Nurse | 163W00000X | 20120231117 | MO | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 53-76912 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.