Healthcare Provider Details

I. General information

NPI: 1023564978
Provider Name (Legal Business Name): NICOLE KENNEY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 E BATTLEFIELD ST
SPRINGFIELD MO
65804-3981
US

IV. Provider business mailing address

PO BOX 505673
SAINT LOUIS MO
63150-5673
US

V. Phone/Fax

Practice location:
  • Phone: 417-889-0056
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2008023403
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016034602
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: