Basic Information
| Provider Information | |||||||||
| NPI: | 1073923140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNON | ||||||||
| FirstName: | KRISTI | ||||||||
| MiddleName: | RAMEY | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9454 THREE RIVERS RD | ||||||||
| Address2: | STE D | ||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395034294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285752660 | ||||||||
| FaxNumber: | 2288630502 | ||||||||
| Practice Location | |||||||||
| Address1: | 2750 GAUSE BLVD E STE 101 | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856393777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2014 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00415 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA.200697 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2365738 | 05 | LA | MEDICAID | 04506043 | 05 | MS | MEDICAID |