Provider Demographics
NPI:1801493275
Name:BOZHANI, DESTEMONA
Entity type:Individual
Prefix:
First Name:DESTEMONA
Middle Name:
Last Name:BOZHANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5804 SW BRAY RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MO
Mailing Address - Zip Code:64430-9176
Mailing Address - Country:US
Mailing Address - Phone:816-262-2889
Mailing Address - Fax:
Practice Address - Street 1:105 FAR WEST DR STE 201
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3514
Practice Address - Country:US
Practice Address - Phone:816-271-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS140231363L00000X
MO2020031429363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care