Provider Demographics
NPI:1003332909
Name:RAFANAN, KENN
Entity Type:Individual
Prefix:
First Name:KENN
Middle Name:
Last Name:RAFANAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 BONANZA AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-5803
Mailing Address - Country:US
Mailing Address - Phone:1818-730-2452
Mailing Address - Fax:
Practice Address - Street 1:2101 ROSECRANS AVE # 3230
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4749
Practice Address - Country:US
Practice Address - Phone:323-628-8671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006905363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily