Provider Demographics
NPI:1093736936
Name:FRAVALA, KENNETH W
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:FRAVALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:W
Other - Last Name:FRAVALA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LT
Mailing Address - Street 1:166 MISHNOCK RD
Mailing Address - Street 2:
Mailing Address - City:WEST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02817-1669
Mailing Address - Country:US
Mailing Address - Phone:401-397-7353
Mailing Address - Fax:401-397-9030
Practice Address - Street 1:166 MISHNOCK RD
Practice Address - Street 2:
Practice Address - City:WEST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02817-1669
Practice Address - Country:US
Practice Address - Phone:401-397-7353
Practice Address - Fax:401-397-9030
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI12469146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0000007822OtherRI BLUE CROSS
RIBQ409256OtherRI BLUE CHIP HMO
RI9007822Medicaid