Provider Demographics
NPI:1760848204
Name:BURNETTE, KENNETH S (NP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:BURNETTE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 MED TECH PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2579
Mailing Address - Country:US
Mailing Address - Phone:423-952-2111
Mailing Address - Fax:423-952-2175
Practice Address - Street 1:111 W STONE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-6027
Practice Address - Country:US
Practice Address - Phone:423-224-3701
Practice Address - Fax:423-224-3709
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN198628163W00000X
VA0024173331363LF0000X
TN20898363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVK418B288Medicare PIN
TN103I503685Medicare PIN