Provider Demographics
NPI:1962060442
Name:TENNYSON, KAITLIN (MD)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:TENNYSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-2504
Mailing Address - Country:US
Mailing Address - Phone:620-343-6800
Mailing Address - Fax:620-341-7821
Practice Address - Street 1:1301 W 12TH AVE STE 301
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-2590
Practice Address - Country:US
Practice Address - Phone:620-343-2376
Practice Address - Fax:620-343-5987
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL0007768207Q00000X
390200000X
KS0446933207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program