Healthcare Provider Details

I. General information

NPI: 1215471008
Provider Name (Legal Business Name): JENNELLE KNIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 N STATE STREET
IOLA KS
66749
US

IV. Provider business mailing address

PO BOX 1832
PITTSBURG KS
66762-1832
US

V. Phone/Fax

Practice location:
  • Phone: 620-380-6400
  • Fax:
Mailing address:
  • Phone: 620-240-5668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number1-16837
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-16837
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: