Provider Demographics
NPI:1467051680
Name:LIETZKE, DEBRA KIM (FNP-C)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:KIM
Last Name:LIETZKE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 N 126TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66109-5121
Mailing Address - Country:US
Mailing Address - Phone:816-509-2052
Mailing Address - Fax:
Practice Address - Street 1:201 NW R D MIZE RD STE 206
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2513
Practice Address - Country:US
Practice Address - Phone:816-655-5403
Practice Address - Fax:816-655-5257
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-79707-031363LF0000X
MO2021007033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily