Healthcare Provider Details

I. General information

NPI: 1154001840
Provider Name (Legal Business Name): KYNDRA BOONE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KYNDRA GAIL BOONE PMHNP

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 07/19/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S FRONT AVE
PRESTONSBURG KY
41653-1614
US

IV. Provider business mailing address

104 S FRONT AVE
PRESTONSBURG KY
41653-1614
US

V. Phone/Fax

Practice location:
  • Phone: 606-886-8572
  • Fax: 606-886-4433
Mailing address:
  • Phone: 606-886-8572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4006541
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: