Provider Demographics
NPI:1417602707
Name:LEGAULT, TINA MARIE (AGNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:LEGAULT
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E 104TH ST
Mailing Address - Street 2:MAILSTOP 400S
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131
Mailing Address - Country:US
Mailing Address - Phone:913-317-3230
Mailing Address - Fax:
Practice Address - Street 1:12330 METCALF AVE STE 580
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-1308
Practice Address - Country:US
Practice Address - Phone:913-317-3230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022007298363LA2200X
KSTMP-160593363LA2200X
KS5380970363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health