=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699033464
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH CARROLL RN, NP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2012
-----------------------------------------------------
Last Update Date | 04/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15708 E 45TH PL S
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64055-5212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-726-5492
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15708 E. 45TH PL. S.
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64055-5212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-726-5492
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 2012009273
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------