Provider Demographics
NPI:1881678555
Name:MCCUNE, KENYON (ARNP)
Entity Type:Individual
Prefix:
First Name:KENYON
Middle Name:
Last Name:MCCUNE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KENYON
Other - Middle Name:
Other - Last Name:TEASLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2633 CENTENNIAL BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0606
Mailing Address - Country:US
Mailing Address - Phone:850-431-5404
Mailing Address - Fax:850-431-4794
Practice Address - Street 1:2633 CENTENNIAL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-431-5404
Practice Address - Fax:850-431-4794
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2117432363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307209600Medicaid
FLY078NOtherBC/BS
FLQ60100Medicare UPIN
FLY078NOtherBC/BS