Provider Demographics
NPI:1215471008
Name:KNIGHT, JENNELLE
Entity type:Individual
Prefix:
First Name:JENNELLE
Middle Name:
Last Name:KNIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1832
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-1832
Mailing Address - Country:US
Mailing Address - Phone:620-240-5668
Mailing Address - Fax:
Practice Address - Street 1:2051 N STATE STREET
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749
Practice Address - Country:US
Practice Address - Phone:620-380-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-16837163WD0400X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100431630AMedicaid
KS0238530003Medicare NSC