Provider Demographics
NPI:1902271489
Name:MT. OREAD FAMILY PRACTICE
Entity Type:Organization
Organization Name:MT. OREAD FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:785-842-5070
Mailing Address - Street 1:3510 CLINTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-2145
Mailing Address - Country:US
Mailing Address - Phone:785-842-5070
Mailing Address - Fax:785-505-5096
Practice Address - Street 1:3510 CLINTON PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047-2145
Practice Address - Country:US
Practice Address - Phone:785-842-5070
Practice Address - Fax:785-505-5096
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAWRENCE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-76993-042261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care