Provider Demographics
NPI:1962887109
Name:GILLENWATER, KELCI BROOKE
Entity type:Individual
Prefix:
First Name:KELCI
Middle Name:BROOKE
Last Name:GILLENWATER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELCI
Other - Middle Name:BROOKE
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:10200 W 105TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-5750
Mailing Address - Country:US
Mailing Address - Phone:913-495-9600
Mailing Address - Fax:913-599-0951
Practice Address - Street 1:10200 W 105TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-5750
Practice Address - Country:US
Practice Address - Phone:913-495-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-76507-042363L00000X
MO2014035979363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner