Provider Demographics
NPI:1629684741
Name:CARLSON, KENYON CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:KENYON
Middle Name:CHRISTOPHER
Last Name:CARLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14300 W BELL RD UNIT 429
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-9735
Mailing Address - Country:US
Mailing Address - Phone:480-652-9723
Mailing Address - Fax:
Practice Address - Street 1:3921 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-1801
Practice Address - Country:US
Practice Address - Phone:605-764-4036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN232862163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool