Provider Demographics
NPI:1154668051
Name:CARLSON, KENNETH (LPN)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18121 E HAMPDEN AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-3591
Mailing Address - Country:US
Mailing Address - Phone:720-379-6572
Mailing Address - Fax:866-538-7337
Practice Address - Street 1:3412 S JEBEL CT
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013-9020
Practice Address - Country:US
Practice Address - Phone:720-379-6572
Practice Address - Fax:866-538-7337
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23173164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse