Individual
MR. LARRY RAY KENNON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
APRN, BC
Contact information
Practice address
1137 INDEPENDENCE DR, WEST PLAINS, MO 65775-4221
(417) 255-8464
Mailing address
7232 COUNTY ROAD 9900, WEST PLAINS, MO 65775-6797
(417) 255-9233
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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