Provider Demographics
NPI:1407964844
Name:PARKER, KENNETH S (ACNP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:PARKER
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-425-5544
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:404 S 13TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4345
Practice Address - Country:US
Practice Address - Phone:601-425-5544
Practice Address - Fax:601-425-5525
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR851488363L00000X
MS851488363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02684504Medicaid
MS3494930OtherAMERICAN ADMIN GROUP
MS3494930OtherAMERICAN ADMIN GROUP
P00308448OtherRAILROAD MEDICARE
Q59346Medicare UPIN