Provider Demographics
NPI:1598102204
Name:KHALILOVA, NICKA (NP)
Entity Type:Individual
Prefix:
First Name:NICKA
Middle Name:
Last Name:KHALILOVA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 WORNALL RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-3241
Mailing Address - Country:US
Mailing Address - Phone:816-932-0340
Mailing Address - Fax:816-932-3148
Practice Address - Street 1:201 NW R D MIZE RD STE 206
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2513
Practice Address - Country:US
Practice Address - Phone:816-655-5403
Practice Address - Fax:816-655-5257
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013015317363LG0600X, 363L00000X, 363LA2200X
MI4704312135363LA2200X
KS75966363L00000X, 363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner