Provider Demographics
NPI:1174408348
Name:KINKENNON, KRISTA S (NP)
Entity type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:S
Last Name:KINKENNON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 230TH ST
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:IA
Mailing Address - Zip Code:50212-7528
Mailing Address - Country:US
Mailing Address - Phone:786-309-8495
Mailing Address - Fax:
Practice Address - Street 1:1014 230TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:IA
Practice Address - Zip Code:50212-7528
Practice Address - Country:US
Practice Address - Phone:786-309-8495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-07
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA11019372363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty