Provider Demographics
NPI:1427054691
Name:WEKENBORG, CRYSTAL ANN (FNP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANN
Last Name:WEKENBORG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:2130 E JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-2907
Practice Address - Country:US
Practice Address - Phone:573-243-3115
Practice Address - Fax:573-243-4700
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO124573363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427325303Medicaid
MO824743853Medicare ID - Type Unspecified
MO427325303Medicaid