Provider Demographics
NPI:1497593693
Name:CHIPMAN, KENNETH BRADLEY (CNP)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:BRADLEY
Last Name:CHIPMAN
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 ALTA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-8810
Mailing Address - Country:US
Mailing Address - Phone:505-573-2723
Mailing Address - Fax:
Practice Address - Street 1:4801 N BUTLER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6002
Practice Address - Country:US
Practice Address - Phone:505-327-0002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-20
Last Update Date:2024-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM80060363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health