Provider Demographics
NPI:1083688584
Name:BRISENO KENNEY, LARA ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:ANNE
Last Name:BRISENO KENNEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LARA
Other - Middle Name:A
Other - Last Name:BRISENO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:LEETON
Mailing Address - State:MO
Mailing Address - Zip Code:64761-0065
Mailing Address - Country:US
Mailing Address - Phone:660-851-4585
Mailing Address - Fax:888-476-8595
Practice Address - Street 1:402 N LEE ST
Practice Address - Street 2:
Practice Address - City:LEETON
Practice Address - State:MO
Practice Address - Zip Code:64761-8200
Practice Address - Country:US
Practice Address - Phone:660-851-4585
Practice Address - Fax:888-476-8595
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301507474207RH0003X
MO2011012603207RH0003X, 207R00000X
OR152755207R00000X
IN01061332A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine