Provider Demographics
NPI:1235613662
Name:WILEY, KENNETH (DNP, CRNA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WILEY
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5000
Mailing Address - Country:US
Mailing Address - Phone:561-316-3019
Mailing Address - Fax:
Practice Address - Street 1:2500 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5000
Practice Address - Country:US
Practice Address - Phone:941-766-4122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9355754163W00000X
FLAPRN11000983367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse