Provider Demographics
NPI:1518299973
Name:POTTEBAUM, MELISSA ANN (MSN)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ANN
Last Name:POTTEBAUM
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:901 E. 104TH ST.
Mailing Address - Street 2:MAILSTOP 400N
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131
Mailing Address - Country:US
Mailing Address - Phone:816-502-7104
Mailing Address - Fax:816-932-9670
Practice Address - Street 1:5844 NW BARRY RD
Practice Address - Street 2:STE 110
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64154-1465
Practice Address - Country:US
Practice Address - Phone:816-880-6100
Practice Address - Fax:816-746-1226
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO145067363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1518299973Medicaid
MO1518299973Medicaid