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General NPI Number Information
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NPI Number | 1003803370
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Entity Type | Individual
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Provider Name | LARRY RAY KENNON APRN, BC
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Gender | Male
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Dates
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Enumeration Date | 10/03/2005
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Last Update Date | 07/22/2013
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Provider Practice Location Address
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Address Line | 1137 INDEPENDENCE DR
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City | WEST PLAINS
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State | MO
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Zip | 65775-4221
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Country | US
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Telephone | 417-255-8464
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Fax |
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Provider Business Mailing Address
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Address Line | 7232 COUNTY ROAD 9900
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City | WEST PLAINS
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State | MO
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Zip | 65775-6797
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Country | US
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Telephone | 417-255-9233
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 061052
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License Number State | MO
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