Provider Demographics
NPI:1417529280
Name:KIOKO, KENNEDY KYALO
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:KYALO
Last Name:KIOKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9315 RIVERA LN APT C
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-6826
Mailing Address - Country:US
Mailing Address - Phone:707-596-2578
Mailing Address - Fax:
Practice Address - Street 1:9315 RIVERA LN APT C
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-6826
Practice Address - Country:US
Practice Address - Phone:707-596-2578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA705786164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse