Provider Demographics
NPI:1245575315
Name:CRAFT, KENNETH LEE JR (FNP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:CRAFT
Suffix:JR
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3983 S MCCARRAN BLVD # 703
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-7510
Mailing Address - Country:US
Mailing Address - Phone:707-315-0961
Mailing Address - Fax:
Practice Address - Street 1:150 COUNTRY ESTATES CIR STE 111
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-4017
Practice Address - Country:US
Practice Address - Phone:888-517-3326
Practice Address - Fax:888-517-3326
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-30
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA726633163W00000X, 163WC1600X
CA22618363LF0000X
NV001840363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100539957Medicaid