Provider Demographics
NPI:1518496660
Name:MOORE, KENNAN ASHTON (FNP)
Entity Type:Individual
Prefix:
First Name:KENNAN
Middle Name:ASHTON
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11818
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1818
Mailing Address - Country:US
Mailing Address - Phone:479-452-6650
Mailing Address - Fax:479-452-5847
Practice Address - Street 1:3117 S 70TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5017
Practice Address - Country:US
Practice Address - Phone:479-785-9400
Practice Address - Fax:479-478-6793
Is Sole Proprietor?:No
Enumeration Date:2017-06-11
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005133363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily