Basic Information
Provider Information
NPI: 1003803370
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KENNON
FirstName: LARRY
MiddleName: RAY
NamePrefix: MR.
NameSuffix:  
Credential: APRN, BC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7232 COUNTY ROAD 9900
Address2:  
City: WEST PLAINS
State: MO
PostalCode: 657756797
CountryCode: US
TelephoneNumber: 4172559233
FaxNumber:  
Practice Location
Address1: 1137 INDEPENDENCE DR
Address2:  
City: WEST PLAINS
State: MO
PostalCode: 657754221
CountryCode: US
TelephoneNumber: 4172558464
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/03/2005
LastUpdateDate: 07/22/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X061052MOY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

ID Information
IDTypeStateIssuerDescription
00001370001 MEDICARE GROUP NUMBEROTHER
42858021105MO MEDICAID
26188201 MEDICARE FQHCOTHER
26186301 MEDICARE FQHCOTHER


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