Provider Demographics
NPI:1578919668
Name:KENNON, KRISTY D (MSN, RN, CPNP)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:D
Last Name:KENNON
Suffix:
Gender:F
Credentials:MSN, RN, CPNP
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:D
Other - Last Name:KOEBERL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 6006B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6299
Mailing Address - Fax:314-251-4450
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-6299
Practice Address - Fax:314-251-4450
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO153988163W00000X
MO2015016097363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse