Provider Demographics
NPI:1750516217
Name:HEFFERNAN, KENNETH RYAN (RD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:RYAN
Last Name:HEFFERNAN
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 SHERINGTON PL
Mailing Address - Street 2:APT G313
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-6043
Mailing Address - Country:US
Mailing Address - Phone:714-916-7136
Mailing Address - Fax:
Practice Address - Street 1:1945 SHERINGTON PL
Practice Address - Street 2:APT G313
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-6043
Practice Address - Country:US
Practice Address - Phone:714-916-7136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered