Provider Demographics
NPI:1972144608
Name:KENNON, BROOKE ASHTON (DNP APRN AG-ACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:ASHTON
Last Name:KENNON
Suffix:
Gender:F
Credentials:DNP APRN AG-ACNP-BC
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:ASHTON
Other - Last Name:LAWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP APRN AG-ACNP-BC
Mailing Address - Street 1:7865 WHITE BLUFF LN APT 201
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-2606
Mailing Address - Country:US
Mailing Address - Phone:731-446-3241
Mailing Address - Fax:
Practice Address - Street 1:1030 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2127
Practice Address - Country:US
Practice Address - Phone:901-523-8990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26355363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1972144608Medicaid