Provider Demographics
NPI:1740042266
Name:LITTLE, KENNON MARK
Entity type:Individual
Prefix:
First Name:KENNON
Middle Name:MARK
Last Name:LITTLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 E 50 S
Mailing Address - Street 2:
Mailing Address - City:ATTICA
Mailing Address - State:IN
Mailing Address - Zip Code:47918-7834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ATTICA
Practice Address - State:IN
Practice Address - Zip Code:47918-1949
Practice Address - Country:US
Practice Address - Phone:765-299-3259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05014715A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist