Provider Demographics
NPI:1538626650
Name:IYEWARUN, ROSE (PHD)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:IYEWARUN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6311 EVANSTON AVE
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-4929
Mailing Address - Country:US
Mailing Address - Phone:816-328-9304
Mailing Address - Fax:
Practice Address - Street 1:6311 EVANSTON AVE
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-4929
Practice Address - Country:US
Practice Address - Phone:816-272-2533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
MO1867261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1700253150Medicaid
MO1952727273Medicaid