Basic Information
| Provider Information | |||||||||
| NPI: | 1548560519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGSTAFF | ||||||||
| FirstName: | KRISTIE | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | WHNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ODEJOKE-MAXWELL | ||||||||
| OtherFirstName: | KRISTIE | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | WHNP-BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3515 BROADWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641112501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167535144 | ||||||||
| FaxNumber: | 8167530804 | ||||||||
| Practice Location | |||||||||
| Address1: | 3515 BROADWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167535144 | ||||||||
| FaxNumber: | 8167530804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2010 | ||||||||
| LastUpdateDate: | 09/24/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 75273 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LW0102X | 2011009868 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.