Provider Demographics
NPI:1326548579
Name:GILLEN, CLARISSA RYAN
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:RYAN
Last Name:GILLEN
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 1:9140 WARD PKWY STE 201
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-3327
Mailing Address - Country:US
Mailing Address - Phone:816-523-0066
Mailing Address - Fax:
Practice Address - Street 1:9140 WARD PKWY STE 201
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-3327
Practice Address - Country:US
Practice Address - Phone:816-523-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO43-1740372208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200297150AMedicaid