Provider Demographics
NPI:1033677679
Name:KENFACK, ETIENNE (APN)
Entity Type:Individual
Prefix:
First Name:ETIENNE
Middle Name:
Last Name:KENFACK
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3142
Mailing Address - Country:US
Mailing Address - Phone:862-224-0668
Mailing Address - Fax:
Practice Address - Street 1:191 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1112
Practice Address - Country:US
Practice Address - Phone:201-656-4324
Practice Address - Fax:201-656-4019
Is Sole Proprietor?:No
Enumeration Date:2019-03-02
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00905700363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology