Provider Demographics
NPI:1457649998
Name:WALLENFELSZ, KENNETH T (ARNP)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:T
Last Name:WALLENFELSZ
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 RANCH RD
Mailing Address - Street 2:
Mailing Address - City:REEDSPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97467-1720
Mailing Address - Country:US
Mailing Address - Phone:541-271-2163
Mailing Address - Fax:541-271-4058
Practice Address - Street 1:620 RANCH RD
Practice Address - Street 2:
Practice Address - City:REEDSPORT
Practice Address - State:OR
Practice Address - Zip Code:97467-1720
Practice Address - Country:US
Practice Address - Phone:541-271-2163
Practice Address - Fax:541-271-4058
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60207225363L00000X
OR201500491NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276263Medicaid
ORMW3446805OtherDEA
OR388513Medicare Oscar/Certification