Provider Demographics
NPI:1003379959
Name:EZENWA, KENNETH (RN)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:EZENWA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17467 HONEY MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91387-6870
Mailing Address - Country:US
Mailing Address - Phone:661-212-5273
Mailing Address - Fax:
Practice Address - Street 1:17467 HONEY MAPLE ST
Practice Address - Street 2:
Practice Address - City:CANYON COUNTRY
Practice Address - State:CA
Practice Address - Zip Code:91387-6870
Practice Address - Country:US
Practice Address - Phone:661-212-5273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95080178163WP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health