Provider Demographics
NPI:1538964705
Name:MIRONCHENKO, OLEG VIKTOR (APRN,MSN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:OLEG
Middle Name:VIKTOR
Last Name:MIRONCHENKO
Suffix:
Gender:M
Credentials:APRN,MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7515 N KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64158-1045
Mailing Address - Country:US
Mailing Address - Phone:860-942-1628
Mailing Address - Fax:
Practice Address - Street 1:4801 E LINWOOD BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64128-2226
Practice Address - Country:US
Practice Address - Phone:816-861-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-13
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024016173163W00000X
KS5382879021363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse