Provider Demographics
NPI:1578231544
Name:LAIRD, KENNETH M (APRN)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:M
Last Name:LAIRD
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830-3 WILLIAMSBURG PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-9244
Mailing Address - Country:US
Mailing Address - Phone:904-403-0593
Mailing Address - Fax:
Practice Address - Street 1:3830-3 WILLIAMSBURG PARK BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-9244
Practice Address - Country:US
Practice Address - Phone:904-403-0593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11015229363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner