Provider Demographics
NPI:1528042439
Name:ANSELMO, MARTALEA (NP)
Entity Type:Individual
Prefix:
First Name:MARTALEA
Middle Name:
Last Name:ANSELMO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARTALEA
Other - Middle Name:
Other - Last Name:GRUBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12200 W 106TH ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66215-2300
Mailing Address - Country:US
Mailing Address - Phone:913-227-0506
Mailing Address - Fax:913-227-0570
Practice Address - Street 1:12200 W 106TH ST
Practice Address - Street 2:SUITE 320
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66215-2300
Practice Address - Country:US
Practice Address - Phone:913-227-0506
Practice Address - Fax:913-227-0570
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45415363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSR57E361Medicare PIN
KSP74016Medicare UPIN