Provider Demographics
NPI:1902412430
Name:HARRIS, KENNETH A (RN, CCRN)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:HARRIS
Suffix:
Gender:M
Credentials:RN, CCRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 COOSADA LN
Mailing Address - Street 2:
Mailing Address - City:COOSADA
Mailing Address - State:AL
Mailing Address - Zip Code:36020-2919
Mailing Address - Country:US
Mailing Address - Phone:334-268-9220
Mailing Address - Fax:
Practice Address - Street 1:20103 LAKE CHABOT RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5305
Practice Address - Country:US
Practice Address - Phone:510-537-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-105100163WG0000X
CA782137163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice