Provider Demographics
NPI:1649604216
Name:RESAUL, KENNY (LPN)
Entity type:Individual
Prefix:MR
First Name:KENNY
Middle Name:
Last Name:RESAUL
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 1:47 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-4731
Mailing Address - Country:US
Mailing Address - Phone:845-499-8849
Mailing Address - Fax:
Practice Address - Street 1:47 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-4731
Practice Address - Country:US
Practice Address - Phone:845-499-8849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302361164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse