Provider Demographics
NPI:1003220245
Name:BOSCH, STACEY R
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:BOSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 SW FRAZIER AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1963
Mailing Address - Country:US
Mailing Address - Phone:785-232-5005
Mailing Address - Fax:
Practice Address - Street 1:4300 BRENNER DR
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66104-1163
Practice Address - Country:US
Practice Address - Phone:913-322-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
KS53-82585363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator