Provider Demographics
NPI:1275131427
Name:MYERS, KEN (FNP-C)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:MYERS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5265 COMMERCE BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-5327
Mailing Address - Country:US
Mailing Address - Phone:855-407-8196
Mailing Address - Fax:
Practice Address - Street 1:5265 COMMERCE BLVD STE D
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-5327
Practice Address - Country:US
Practice Address - Phone:855-407-8196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-10
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010217A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty