Basic Information
| Provider Information | |||||||||
| NPI: | 1518299973 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTTEBAUM | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 E. 104TH ST. | ||||||||
| Address2: | MAILSTOP 400N | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165027104 | ||||||||
| FaxNumber: | 8169329670 | ||||||||
| Practice Location | |||||||||
| Address1: | 5844 NW BARRY RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641541465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168806100 | ||||||||
| FaxNumber: | 8167461226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2010 | ||||||||
| LastUpdateDate: | 02/07/2018 | ||||||||
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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 | 363LW0102X | 145067 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 1518299973 | 05 | MO | MEDICAID |