Provider Demographics
NPI:1861049215
Name:CHUKWUSOM, GLORY I (APRN)
Entity type:Individual
Prefix:
First Name:GLORY
Middle Name:I
Last Name:CHUKWUSOM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6530 TROOST AVE STE A
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-1301
Mailing Address - Country:US
Mailing Address - Phone:816-361-0670
Mailing Address - Fax:816-444-6936
Practice Address - Street 1:6530 TROOST AVE STE A
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-1301
Practice Address - Country:US
Practice Address - Phone:816-361-0670
Practice Address - Fax:816-444-6936
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019020223363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner