Provider Demographics
NPI:1356385082
Name:NORDLUND, KENNETH WAYNE (NP)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:NORDLUND
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 N SUNRISE WAY
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-3701
Mailing Address - Country:US
Mailing Address - Phone:760-323-2118
Mailing Address - Fax:510-879-9100
Practice Address - Street 1:58581 US HIGHWAY 371 STE F, G, H
Practice Address - Street 2:
Practice Address - City:ANZA
Practice Address - State:CA
Practice Address - Zip Code:92539-9331
Practice Address - Country:US
Practice Address - Phone:951-763-4759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN428808163W00000X
CANPF10271363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22732ZMedicare PIN
CAS67383Medicare UPIN