Provider Demographics
NPI:1437561743
Name:DUFFY, KENNETH JR
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:DUFFY
Suffix:JR
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 1:4100 CORPORATE SQ
Mailing Address - Street 2:STE 153
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34104-4714
Mailing Address - Country:US
Mailing Address - Phone:239-331-8690
Mailing Address - Fax:
Practice Address - Street 1:1800 W 49TH ST
Practice Address - Street 2:STE 717
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2900
Practice Address - Country:US
Practice Address - Phone:239-331-8690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL232728372600000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005937900Medicaid