Basic Information
| Provider Information | |||||||||
| NPI: | 1598378986 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIRK | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | DEE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4747 S BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672161739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169938123 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4747 S BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672161739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3165293084 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2020 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F01200572 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 5379282012 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201337300A | 05 | KS | MEDICAID | 53-79282-012 | 01 | KS | KANSAS STATE BOARD OF NURSING | OTHER | 112613 | 01 | KS | KSBN-RN | OTHER | 1598378986 | 01 | KS | NPI | OTHER |