Provider Demographics
NPI:1063048817
Name:POORE, KENITA (NP)
Entity type:Individual
Prefix:
First Name:KENITA
Middle Name:
Last Name:POORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KENITA
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:314-543-6979
Mailing Address - Fax:314-364-6321
Practice Address - Street 1:1001 S HORSEBARN RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8184
Practice Address - Country:US
Practice Address - Phone:479-273-7700
Practice Address - Fax:479-646-7734
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR124002363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty