Provider Demographics
NPI:1548560519
Name:WAGSTAFF, KRISTIE RENEE (WHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIE
Middle Name:RENEE
Last Name:WAGSTAFF
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:MS
Other - First Name:KRISTIE
Other - Middle Name:RENEE
Other - Last Name:ODEJOKE-MAXWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:WHNP-BC
Mailing Address - Street 1:3515 BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-2501
Mailing Address - Country:US
Mailing Address - Phone:816-753-5144
Mailing Address - Fax:816-753-0804
Practice Address - Street 1:3515 BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111
Practice Address - Country:US
Practice Address - Phone:816-753-5144
Practice Address - Fax:816-753-0804
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS75273363LW0102X
MO2011009868363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2011009868OtherLICENSE
MO2011009868OtherLICENSE