Provider Demographics
NPI:1265104871
Name:KROENKE, ZACHARY (AGACNP-BC, APRN)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:KROENKE
Suffix:
Gender:M
Credentials:AGACNP-BC, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12685 N PEACH BLOSSOM CT
Mailing Address - Street 2:
Mailing Address - City:PLATTE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64079-4519
Mailing Address - Country:US
Mailing Address - Phone:402-770-2070
Mailing Address - Fax:
Practice Address - Street 1:12685 N PEACH BLOSSOM CT
Practice Address - Street 2:
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-4519
Practice Address - Country:US
Practice Address - Phone:402-770-2070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-01
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019029494163W00000X
MO2021041008363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2021041008OtherAPRN LICENSE
MO2019029494OtherMISSOURI STATE BOARD OF NURSING