Provider Demographics
NPI:1104273317
Name:CARROLL, ANGELIQUE IRENE
Entity type:Individual
Prefix:MRS
First Name:ANGELIQUE
Middle Name:IRENE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ANGELIQUE
Other - Middle Name:IRENE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8717 W 110TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2144
Mailing Address - Country:US
Mailing Address - Phone:913-428-2900
Mailing Address - Fax:913-428-2951
Practice Address - Street 1:19600 E 39TH ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2301
Practice Address - Country:US
Practice Address - Phone:913-428-2900
Practice Address - Fax:913-428-2951
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016019530367500000X
MO2007029371163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered