Provider Demographics
NPI:1013583368
Name:KENNON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KENNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 DAWSON RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72936-8546
Mailing Address - Country:US
Mailing Address - Phone:479-357-5140
Mailing Address - Fax:
Practice Address - Street 1:910 S GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4130
Practice Address - Country:US
Practice Address - Phone:479-926-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician