Provider Demographics
NPI:1487022471
Name:GAUSTAD, KYLIE IMMETHUN (APRN)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:IMMETHUN
Last Name:GAUSTAD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:ANNE
Other - Last Name:IMMETHUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6013 LEAVENWORTH RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66104-1436
Mailing Address - Country:US
Mailing Address - Phone:816-599-5111
Mailing Address - Fax:
Practice Address - Street 1:6013 LEAVENWORTH RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66104-1436
Practice Address - Country:US
Practice Address - Phone:913-321-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS111908-101163W00000X
MO20120231117163W00000X
KS53-76912363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse