Provider Demographics
NPI:1073923140
Name:KENNON, KRISTI RAMEY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KRISTI
Middle Name:RAMEY
Last Name:KENNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9454 THREE RIVERS RD
Mailing Address - Street 2:STE D
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4294
Mailing Address - Country:US
Mailing Address - Phone:228-575-2660
Mailing Address - Fax:228-863-0502
Practice Address - Street 1:2750 GAUSE BLVD E STE 101
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461
Practice Address - Country:US
Practice Address - Phone:985-639-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00415363A00000X
LAPA.200697363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2365738Medicaid
MS04506043Medicaid
LA344675YH3UMedicare PIN