Provider Demographics
NPI:1679757116
Name:BREESE, SUE ELLEN (ANP-BC)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:ELLEN
Last Name:BREESE
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:ELLEN
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5950 N OAK TRFY STE 104
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64118-5164
Mailing Address - Country:US
Mailing Address - Phone:816-268-8501
Mailing Address - Fax:
Practice Address - Street 1:5950 N. OAK TRFY
Practice Address - Street 2:SUITE 104
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-5164
Practice Address - Country:US
Practice Address - Phone:816-268-8501
Practice Address - Fax:816-452-5700
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-97852-042163W00000X
MO2001005022163W00000X, 363LP0808X, 363LA2200X
KS53-46184-042363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1679757116Medicaid
KS200633510BMedicaid
KS200633510BMedicaid
MOP010154985Medicare PIN