Provider Demographics
NPI:1689325425
Name:IRVIN, KENYATTA (NP)
Entity Type:Individual
Prefix:
First Name:KENYATTA
Middle Name:
Last Name:IRVIN
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 1:19401 PARTHENIA ST APT 1040
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-3241
Mailing Address - Country:US
Mailing Address - Phone:562-552-1374
Mailing Address - Fax:
Practice Address - Street 1:607 W AVENUE Q STE A
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-3872
Practice Address - Country:US
Practice Address - Phone:562-552-1374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018472363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner