Provider Demographics
NPI:1659562528
Name:NORMAN, KENYATTA D (MD)
Entity Type:Individual
Prefix:
First Name:KENYATTA
Middle Name:D
Last Name:NORMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 WASHINGTON AVE
Mailing Address - Street 2:STE 518
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1996
Mailing Address - Country:US
Mailing Address - Phone:317-345-7518
Mailing Address - Fax:
Practice Address - Street 1:1209 WASHINGTON AVE
Practice Address - Street 2:STE 518
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1996
Practice Address - Country:US
Practice Address - Phone:317-345-7518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036128850207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
00198004Medicare PIN