Basic Information
| Provider Information | |||||||||
| NPI: | 1457479859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | C.P.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 GILLHAM RD | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641084619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167015200 | ||||||||
| FaxNumber: | 8163029939 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 GILLHAM RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641084619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162343000 | ||||||||
| FaxNumber: | 8168551941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 02/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 148062 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 45952 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.