Healthcare Provider Details

I. General information

NPI: 1689710899
Provider Name (Legal Business Name): GREGORY D KINGSTON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S 20TH ST
PADUCAH KY
42001-7100
US

IV. Provider business mailing address

117 S 2ND ST PO BOX 497
AUGUSTA AR
72006-2309
US

V. Phone/Fax

Practice location:
  • Phone: 270-575-3247
  • Fax: 270-442-7335
Mailing address:
  • Phone: 870-347-2534
  • Fax: 870-347-3492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3002602
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: