Basic Information
Provider Information | |||||||||
NPI: | 1326560525 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOYDSTUN | ||||||||
FirstName: | KATIE | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5900 W STONEY BROOK RD APT 2102 | ||||||||
Address2: |   | ||||||||
City: | ROGERS | ||||||||
State: | AR | ||||||||
PostalCode: | 727584625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3093353353 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3901 RAINBOW BLVD | ||||||||
Address2: |   | ||||||||
City: | KANSAS CITY | ||||||||
State: | KS | ||||||||
PostalCode: | 661608500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9135881227 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2017 | ||||||||
LastUpdateDate: | 07/10/2017 | ||||||||
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 | 163W00000X | 2015014686 | MO | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | 112814 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.