Individual
MR. LARRY RAY KENNON
Active
Individual
MR. LARRY RAY KENNON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
APRN, BC
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
061052
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000013700
MEDICARE GROUP NUMBER
—
01
—
261863
MEDICARE FQHC
—
01
—
261882
MEDICARE FQHC
—
05
—
428580211
—
MO
Enumeration date
10/03/2005
Last updated
07/22/2013
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