Provider Demographics
NPI:1336182856
Name:WARE, KENNA LAINE (AP, DOM)
Entity Type:Individual
Prefix:MRS
First Name:KENNA
Middle Name:LAINE
Last Name:WARE
Suffix:
Gender:F
Credentials:AP, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2939 WILLOW BAY TER
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-6735
Mailing Address - Country:US
Mailing Address - Phone:407-782-1934
Mailing Address - Fax:
Practice Address - Street 1:1340 TUSKAWILLA RD STE 111
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-5030
Practice Address - Country:US
Practice Address - Phone:407-782-1934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP565171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102471100Medicaid