Provider Demographics
NPI:1275307936
Name:DAKA, KIDIST
Entity Type:Individual
Prefix:
First Name:KIDIST
Middle Name:
Last Name:DAKA
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 1:12501 BENSON ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-1791
Mailing Address - Country:US
Mailing Address - Phone:913-638-0021
Mailing Address - Fax:
Practice Address - Street 1:2000 OLATHE FL 5
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-8505
Practice Address - Country:US
Practice Address - Phone:913-588-6022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-82667-072364SC2300X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No364SC2300XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistChronic Care