Provider Demographics
NPI:1629576244
Name:HERRICK, KENNETH (NP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:HERRICK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12550 HESPERIA RD # 101
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5873
Mailing Address - Country:US
Mailing Address - Phone:760-381-7703
Mailing Address - Fax:
Practice Address - Street 1:17043 MAIN ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-6055
Practice Address - Country:US
Practice Address - Phone:760-241-6666
Practice Address - Fax:760-243-2099
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008084363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner