Provider Demographics
NPI:1023564978
Name:KENNEY, NICOLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KENNEY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 E BATTLEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-3981
Mailing Address - Country:US
Mailing Address - Phone:417-889-0056
Mailing Address - Fax:
Practice Address - Street 1:2715 E BATTLEFIELD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-3981
Practice Address - Country:US
Practice Address - Phone:417-889-0056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008023403163W00000X
MO2016034602363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPENDINGMedicaid
MOPENDINGMedicaid
MOPENDINGMedicare PIN