Provider Demographics
NPI:1831297266
Name:BAKER, KENNETH W (FNP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:BAKER
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 DAVIS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-9162
Mailing Address - Country:US
Mailing Address - Phone:817-991-9730
Mailing Address - Fax:
Practice Address - Street 1:3917 W CAMP WISDOM RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-2468
Practice Address - Country:US
Practice Address - Phone:972-709-7259
Practice Address - Fax:972-709-7252
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX577002363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health