Provider Demographics
NPI:1629013271
Name:REICHARDT, KYRA L (NP)
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:L
Last Name:REICHARDT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803
Mailing Address - Country:US
Mailing Address - Phone:417-782-3000
Mailing Address - Fax:417-782-3088
Practice Address - Street 1:1102 W 32ND STREET
Practice Address - Street 2:STE 300
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-782-3000
Practice Address - Fax:417-782-3088
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO129112363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100414280AMedicaid
500022358OtherRR MEDICARE
MO162696OtherANTHEM
OK100145070AMedicaid
MO425753100Medicaid
MO162696OtherANTHEM
KS100414280AMedicaid