Provider Demographics
NPI:1861018350
Name:KENNON, LACEY DESHAY (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:DESHAY
Last Name:KENNON
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7509 RED PINE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-8809
Mailing Address - Country:US
Mailing Address - Phone:479-414-9629
Mailing Address - Fax:
Practice Address - Street 1:7509 RED PINE DR
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72916-8809
Practice Address - Country:US
Practice Address - Phone:479-414-9629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARF06201581363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily