Healthcare Provider Details

I. General information

NPI: 1003803370
Provider Name (Legal Business Name): LARRY RAY KENNON APRN, BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1137 INDEPENDENCE DR
WEST PLAINS MO
65775-4221
US

IV. Provider business mailing address

7232 COUNTY ROAD 9900
WEST PLAINS MO
65775-6797
US

V. Phone/Fax

Practice location:
  • Phone: 417-255-8464
  • Fax:
Mailing address:
  • Phone: 417-255-9233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number061052
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: