Provider Demographics
NPI:1093117624
Name:MBOULE, AMMIE SHEREE (BS)
Entity Type:Individual
Prefix:MRS
First Name:AMMIE
Middle Name:SHEREE
Last Name:MBOULE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E AUGUSTA AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:KS
Mailing Address - Zip Code:67010-2100
Mailing Address - Country:US
Mailing Address - Phone:316-775-5491
Mailing Address - Fax:316-775-5442
Practice Address - Street 1:520 E AUGUSTA AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:KS
Practice Address - Zip Code:67010-2100
Practice Address - Country:US
Practice Address - Phone:316-775-5491
Practice Address - Fax:316-775-5442
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator