Provider Demographics
NPI:1114948627
Name:MAMMEN, KATHLEEN D (APRN FNP BC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:D
Last Name:MAMMEN
Suffix:
Gender:F
Credentials:APRN FNP BC
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:D
Other - Last Name:KOPPENHAFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN FNP BC
Mailing Address - Street 1:825 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64124-2323
Mailing Address - Country:US
Mailing Address - Phone:816-889-4614
Mailing Address - Fax:816-889-4847
Practice Address - Street 1:825 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64124-2323
Practice Address - Country:US
Practice Address - Phone:816-889-4614
Practice Address - Fax:816-889-4847
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005017142363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3046869 00Medicaid
MO421441304Medicaid
MOC16E724OtherMEDICARE B WHEATLANDS
MOC16E724OtherMEDICARE B WHEATLANDS
SCP297966850Medicare ID - Type Unspecified