Provider Demographics
NPI:1992056816
Name:KENEBREW, JOYCE LOUISE (APN)
Entity type:Individual
Prefix:
First Name:JOYCE
Middle Name:LOUISE
Last Name:KENEBREW
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:JOYCE
Other - Middle Name:
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7251 LAGUNA
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-0138
Mailing Address - Country:US
Mailing Address - Phone:832-549-0984
Mailing Address - Fax:
Practice Address - Street 1:1201 S SHERMAN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-6507
Practice Address - Country:US
Practice Address - Phone:972-925-9087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX756942363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX312230101Medicaid
TX259384YKQHMedicare PIN