Provider Demographics
NPI:1780043406
Name:WARNER, KENNETH (RN)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WARNER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 HIGHGATE ST APT 11
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-3088
Mailing Address - Country:US
Mailing Address - Phone:541-441-6868
Mailing Address - Fax:
Practice Address - Street 1:777 MURPHY RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8425
Practice Address - Country:US
Practice Address - Phone:541-772-7263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR098007190RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse