Provider Demographics
NPI:1114561925
Name:ENSWORTH, KERIANN
Entity Type:Individual
Prefix:
First Name:KERIANN
Middle Name:
Last Name:ENSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 MURPHY RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8425
Mailing Address - Country:US
Mailing Address - Phone:541-772-2763
Mailing Address - Fax:541-734-3164
Practice Address - Street 1:777 MURPHY RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8425
Practice Address - Country:US
Practice Address - Phone:541-772-2763
Practice Address - Fax:541-734-3164
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201900725LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse