Provider Demographics
NPI:1457036337
Name:OYALO, KENNEDY OTIENO
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:OTIENO
Last Name:OYALO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9858 E HAY LOFT DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AZ
Mailing Address - Zip Code:85132-7369
Mailing Address - Country:US
Mailing Address - Phone:480-578-3995
Mailing Address - Fax:
Practice Address - Street 1:9858 E HAY LOFT DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85132-7369
Practice Address - Country:US
Practice Address - Phone:480-578-3995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
AZ11745797251S00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty