Healthcare Provider Details

I. General information

NPI: 1861018350
Provider Name (Legal Business Name): LACEY DESHAY KENNON APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 WE KNIGHT DR
FORT SMITH AR
72903-6254
US

IV. Provider business mailing address

3501 WE KNIGHT DR
FORT SMITH AR
72903-6254
US

V. Phone/Fax

Practice location:
  • Phone: 479-414-9629
  • Fax:
Mailing address:
  • Phone: 479-709-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number212497
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06201581
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: