Provider Demographics
NPI:1477684678
Name:POECKER, KIMBERLY JO (DO)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JO
Last Name:POECKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JO
Other - Last Name:QUACKENBUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:901 E 104TH ST
Mailing Address - Street 2:MS 400S
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131
Mailing Address - Country:US
Mailing Address - Phone:816-502-8752
Mailing Address - Fax:
Practice Address - Street 1:4401 WORNALL RD
Practice Address - Street 2:REHABILITATION SERVICES MAIN 4
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3220
Practice Address - Country:US
Practice Address - Phone:816-932-2020
Practice Address - Fax:816-932-6211
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009006316208100000X
KS05-33658208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS05-33658OtherSTATE OF KANSAS
MO1477684678Medicaid
MO2009006316OtherSTATE OF MISSOURI
KS05-33658OtherSTATE OF KANSAS
MO2009006316OtherSTATE OF MISSOURI