Provider Demographics
NPI:1518410596
Name:CUSTER, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:CUSTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3162 SW GARDENIA ST
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081-3874
Mailing Address - Country:US
Mailing Address - Phone:913-449-1299
Mailing Address - Fax:
Practice Address - Street 1:4801 E LINWOOD BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64128-2226
Practice Address - Country:US
Practice Address - Phone:816-861-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012038032163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical