Provider Demographics
NPI:1063539823
Name:VAN ROSS, SYREETA LYNN
Entity type:Individual
Prefix:
First Name:SYREETA
Middle Name:LYNN
Last Name:VAN ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SYREETA
Other - Middle Name:LYNN
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 CARONDELET DR STE 100
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-4673
Mailing Address - Country:US
Mailing Address - Phone:816-941-9030
Mailing Address - Fax:816-941-4416
Practice Address - Street 1:1000 CARONDELET DR STE 100
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4673
Practice Address - Country:US
Practice Address - Phone:816-941-9030
Practice Address - Fax:816-941-4416
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS200380880A171W00000X
KS77550-072363LP2300X
MO2015039584363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No171W00000XOther Service ProvidersContractor
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200380880AMedicaid