Provider Demographics
NPI:1467016618
Name:CHIN, KENIA ELIZABETH
Entity Type:Individual
Prefix:
First Name:KENIA
Middle Name:ELIZABETH
Last Name:CHIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6841 SW 147TH AVE APT 3G
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1012
Mailing Address - Country:US
Mailing Address - Phone:786-747-8002
Mailing Address - Fax:
Practice Address - Street 1:6841 SW 147TH AVE APT 3G
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-1012
Practice Address - Country:US
Practice Address - Phone:786-747-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103690700261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103690700Medicaid