Provider Demographics
NPI:1407410210
Name:EUBANK, MALLORY (MSN, APRN-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:EUBANK
Suffix:
Gender:F
Credentials:MSN, APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9022 NE 103RD TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64157-7872
Mailing Address - Country:US
Mailing Address - Phone:816-560-6300
Mailing Address - Fax:
Practice Address - Street 1:2100 SE BLUE PKWY
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-1007
Practice Address - Country:US
Practice Address - Phone:816-282-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018043924363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily