Provider Demographics
NPI:1619213576
Name:KALLENBACH, DARYL JOHN (CNA)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:JOHN
Last Name:KALLENBACH
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 BEEFEATER DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404-1953
Mailing Address - Country:US
Mailing Address - Phone:928-706-5851
Mailing Address - Fax:
Practice Address - Street 1:3465 THUNDERBIRD LN
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406-5556
Practice Address - Country:US
Practice Address - Phone:928-706-5851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCNA1000021924374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide