Provider Demographics
NPI:1679346290
Name:BOONE, KENNETH J SR (MD - INTERN)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:BOONE
Suffix:SR
Gender:M
Credentials:MD - INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 S EASTERN AVE., STE. 6
Mailing Address - Street 2:UNIT 126
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119
Mailing Address - Country:US
Mailing Address - Phone:716-308-0228
Mailing Address - Fax:
Practice Address - Street 1:1703 CIVIC CENTER DR STE 5
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7273
Practice Address - Country:US
Practice Address - Phone:716-308-0228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI5343101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor