Provider Demographics
NPI:1730718867
Name:KOSTELAC, SAMANTHA LYNN (FNP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:KOSTELAC
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:LYNN
Other - Last Name:NOLKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:901 E 104TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-4517
Mailing Address - Country:US
Mailing Address - Phone:816-960-7600
Mailing Address - Fax:816-960-7699
Practice Address - Street 1:4400 BROADWAY BLVD STE 520
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3342
Practice Address - Country:US
Practice Address - Phone:816-960-7600
Practice Address - Fax:816-960-7699
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013017085163WC0200X, 163WN0800X
KS5379596363LF0000X
390200000X
MO2020022341363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program