Provider Demographics
NPI:1942496286
Name:NENNINGER, KATHLEEN MARIE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:NENNINGER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3319 SPRING STREET
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807
Mailing Address - Country:US
Mailing Address - Phone:563-359-1641
Mailing Address - Fax:563-359-4634
Practice Address - Street 1:3319 SPRING STREET
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807
Practice Address - Country:US
Practice Address - Phone:563-359-1641
Practice Address - Fax:563-359-4634
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA097666208800000X
IL209006832208800000X
IA097666363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0184500001Medicare NSC
IL0184500003Medicare NSC
IA07364Medicare PIN
IL336552Medicare PIN