Provider Demographics
NPI:1629654298
Name:BUCHANAN, KYRIA ANASTASIA (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:KYRIA
Middle Name:ANASTASIA
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:KYRIA
Other - Middle Name:
Other - Last Name:KONIECZNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:405 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1322
Mailing Address - Country:US
Mailing Address - Phone:813-838-2707
Mailing Address - Fax:
Practice Address - Street 1:12 N 64TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3809
Practice Address - Country:US
Practice Address - Phone:618-877-4420
Practice Address - Fax:618-397-0093
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021010405363LP0808X
IL209023411363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health