Provider Demographics
NPI:1427054774
Name:NOLAN, SANDRA J (APRN)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:NOLAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:J
Other - Last Name:SMART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:901 E 104TH ST
Mailing Address - Street 2:MAILSTOP 400S
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131
Mailing Address - Country:US
Mailing Address - Phone:816-502-7117
Mailing Address - Fax:816-932-9670
Practice Address - Street 1:601 S 169 HWY
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:MO
Practice Address - Zip Code:64089
Practice Address - Country:US
Practice Address - Phone:913-684-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-134927-112163W00000X
IL2090009004363LP0808X
MO096307363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO096307OtherLICENSE
MO424769115Medicaid
MT0MT0372665OtherBLUE CROSS-SHIELD OF MONTANA
MOS99021Medicare UPIN
MTM011007714Medicare PIN