MEDICARE: KENNY CHRYSOSTOME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	0041464	OH
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	NP004147	GA
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN11042205	FL
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	CNP251894	ME

General Provider Information

NPI Number	:	1407569817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNY CHRYSOSTOME

Provider Business Mailing Address
First Line	:	115 JAY CT
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-1723
Country	:	US
Telephone Number	:	561-797-9787
Fax Number	:

Provider Business Practice Location Address
First Line	:	4810 RIVERSTONE BLVD STE 100
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-4092
Country	:	US
Telephone Number	:	877-744-6483
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2022
Last Update Date	:	02/17/2026

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Directions to “ KENNY CHRYSOSTOME ” Practice Location

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