Provider Demographics
NPI:1164935599
Name:ANDERSON, KENYATTA DENISE (FNP-C)
Entity Type:Individual
Prefix:
First Name:KENYATTA
Middle Name:DENISE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KENYATTA
Other - Middle Name:DEVISE
Other - Last Name:VANCE-ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5357 BROADVIEW RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-1607
Mailing Address - Country:US
Mailing Address - Phone:440-263-6120
Mailing Address - Fax:
Practice Address - Street 1:12914 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-1859
Practice Address - Country:US
Practice Address - Phone:216-848-9123
Practice Address - Fax:216-848-9123
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH024369363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily