Provider Demographics
NPI:1255703310
Name:ACKLEY, KENNETH WAYNE (LPN)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:ACKLEY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHIMNEY POINT DRIVE
Mailing Address - Street 2:
Mailing Address - City:OGDENSBUG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-2291
Mailing Address - Country:US
Mailing Address - Phone:315-323-7071
Mailing Address - Fax:315-541-2041
Practice Address - Street 1:16 AMPERSAND DRIVE
Practice Address - Street 2:
Practice Address - City:PLATTSBUGH
Practice Address - State:NY
Practice Address - Zip Code:12901
Practice Address - Country:US
Practice Address - Phone:315-323-7071
Practice Address - Fax:518-566-0168
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY264405-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse