Basic Information
| Provider Information | |||||||||
| NPI: | 1881900058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DERGANC | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 SW MULVANE ST | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666061677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853570301 | ||||||||
| FaxNumber: | 7853576589 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MERCY WAY | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648044524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175562727 | ||||||||
| FaxNumber: | 7853576589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2010 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 141458 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 2012035666 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 068002116 | 01 | KS | MEDICARE PTAN | OTHER | 200674390B | 05 | KS | MEDICAID |