Basic Information
| Provider Information | |||||||||
| NPI: | 1902271489 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MT. OREAD FAMILY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3510 CLINTON PKWY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660472145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858425070 | ||||||||
| FaxNumber: | 7855055096 | ||||||||
| Practice Location | |||||||||
| Address1: | 3510 CLINTON PKWY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660472145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858425070 | ||||||||
| FaxNumber: | 7855055096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2015 | ||||||||
| LastUpdateDate: | 12/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | JIMENEZ | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | SUZANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | FAMILY NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 7858425070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAWRENCE MEMORIAL HOSPITAL | ||||||||
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| AuthorizedOfficialCredential: | APRN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 53-76993-042 | KS | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.