Provider Demographics
NPI:1740657451
Name:SKJERVEM, CARLY D
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:D
Last Name:SKJERVEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:D
Other - Last Name:WELCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 CHARLOTTE ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-2727
Mailing Address - Country:US
Mailing Address - Phone:816-404-7800
Mailing Address - Fax:816-404-6006
Practice Address - Street 1:2101 CHARLOTTE ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2727
Practice Address - Country:US
Practice Address - Phone:816-404-7800
Practice Address - Fax:816-404-6006
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016021952363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420035712Medicaid