Provider Demographics
NPI:1003473778
Name:ZIMMERMAN, KELSIE MARIE
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:MARIE
Last Name:ZIMMERMAN
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 1:6010 THEDEN ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66218-9257
Mailing Address - Country:US
Mailing Address - Phone:913-961-6897
Mailing Address - Fax:
Practice Address - Street 1:4000 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-9257
Practice Address - Country:US
Practice Address - Phone:913-588-8503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS15-02264363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program