Provider Demographics
NPI:1518356427
Name:ILDEFONSO, KENNETH JR (ATR)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:ILDEFONSO
Suffix:JR
Gender:M
Credentials:ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 MONKS AVE
Mailing Address - Street 2:APARTMENT 413
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 MONKS AVE
Practice Address - Street 2:APARTMENT 413
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6356
Practice Address - Country:US
Practice Address - Phone:203-584-3347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer