Provider Demographics
NPI:1447816855
Name:HAGEN, KENYON MICHELLE (FNP-NC)
Entity type:Individual
Prefix:MRS
First Name:KENYON
Middle Name:MICHELLE
Last Name:HAGEN
Suffix:
Gender:F
Credentials:FNP-NC
Other - Prefix:MRS
Other - First Name:KENYON
Other - Middle Name:MICHELLE
Other - Last Name:PUETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN-BSN
Mailing Address - Street 1:1307 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOCKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65682-8327
Mailing Address - Country:US
Mailing Address - Phone:417-232-4560
Mailing Address - Fax:
Practice Address - Street 1:1307 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOCKWOOD
Practice Address - State:MO
Practice Address - Zip Code:65682-8327
Practice Address - Country:US
Practice Address - Phone:417-232-4560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019012911363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily