Provider Demographics
NPI:1548436561
Name:NIEBUHR, BREANNE MICHELLE (OD)
Entity type:Individual
Prefix:DR
First Name:BREANNE
Middle Name:MICHELLE
Last Name:NIEBUHR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:BREANNE
Other - Middle Name:MICHELLE
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2401 GILLHAM RD
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-4619
Mailing Address - Country:US
Mailing Address - Phone:816-701-5211
Mailing Address - Fax:816-302-9939
Practice Address - Street 1:5808 W 110TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-2504
Practice Address - Country:US
Practice Address - Phone:913-696-8000
Practice Address - Fax:816-302-9939
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1178152W00000X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS6367830001Medicare NSC