Provider Demographics
NPI:1013954601
Name:BOMAR, MARILEE GREEN (MSN)
Entity Type:Individual
Prefix:
First Name:MARILEE
Middle Name:GREEN
Last Name:BOMAR
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:MARILEE
Other - Middle Name:SUE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:551 E SOUTHAMPTON DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-4236
Practice Address - Country:US
Practice Address - Phone:573-884-7733
Practice Address - Fax:573-882-6228
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO128845363L00000X, 364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420750200Medicaid
MO420750200Medicaid
MO205801OtherBLUE CHOICE
MO205801OtherBLUE SHIELD
MOQ68242Medicare UPIN