Provider Demographics
NPI:1205189388
Name:ANDERSON, KENYA DIANE (CNA)
Entity Type:Individual
Prefix:MISS
First Name:KENYA
Middle Name:DIANE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11739 CRESCENT PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-7863
Mailing Address - Country:US
Mailing Address - Phone:352-255-6458
Mailing Address - Fax:
Practice Address - Street 1:11739 CRESCENT PINES BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-7863
Practice Address - Country:US
Practice Address - Phone:352-255-6458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNA0006346680171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator