Provider Demographics
NPI:1811443070
Name:LODDER, MIKALA MARIE (AG-ACNP)
Entity type:Individual
Prefix:
First Name:MIKALA
Middle Name:MARIE
Last Name:LODDER
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9200 INDIAN CREEK PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2008
Mailing Address - Country:US
Mailing Address - Phone:913-574-2800
Mailing Address - Fax:913-574-2336
Practice Address - Street 1:8700 N GREEN HILLS RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64154-1910
Practice Address - Country:US
Practice Address - Phone:913-574-2520
Practice Address - Fax:913-574-2612
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-77352-121363LA2100X
MO2017016078363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201154160BMedicaid
MO1811443070Medicaid