Healthcare Provider Details

I. General information

NPI: 1124067590
Provider Name (Legal Business Name): DONITA KI BOAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DONITA KI KENNEDY D.O.

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 W 32ND ST
JOPLIN MO
64804-3503
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803-3810
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-1078
  • Fax: 417-347-1079
Mailing address:
  • Phone: 417-347-1078
  • Fax: 417-347-1079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2006013764
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4085
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: