Provider Demographics
NPI:1487112215
Name:BERWALDT, ELIZABETH ALLISON RUTH (FNP-BC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ALLISON RUTH
Last Name:BERWALDT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ALLISON RUTH
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9411 N. OAK TRAFFICWAY
Mailing Address - Street 2:LL1
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-2144
Mailing Address - Country:US
Mailing Address - Phone:816-691-1655
Mailing Address - Fax:913-428-2951
Practice Address - Street 1:2790 CLAY EDWARDS DR STE 520
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3274
Practice Address - Country:US
Practice Address - Phone:816-221-6750
Practice Address - Fax:816-221-7280
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022046158363LF0000X
KS5378555072363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1174504732Medicaid