Healthcare Provider Details

I. General information

NPI: 1962060442
Provider Name (Legal Business Name): KAITLIN TENNYSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W 12TH AVE STE 301
EMPORIA KS
66801-2590
US

IV. Provider business mailing address

1201 W 12TH AVE
EMPORIA KS
66801-2504
US

V. Phone/Fax

Practice location:
  • Phone: 620-343-2376
  • Fax: 620-343-5987
Mailing address:
  • Phone: 620-343-6800
  • Fax: 620-341-7821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTL0007768
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0446933
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: