Provider Demographics
NPI:1033758685
Name:PERRY, KENNETH ROY (NURSE)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROY
Last Name:PERRY
Suffix:
Gender:M
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8611 MONTEREY FLS
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78015-2106
Mailing Address - Country:US
Mailing Address - Phone:210-884-4483
Mailing Address - Fax:
Practice Address - Street 1:127 CLOUDHAVEN DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-4339
Practice Address - Country:US
Practice Address - Phone:210-319-0041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX578178163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse