Provider Demographics
NPI:1811310253
Name:KALLIES, KENNETH (RN)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:KALLIES
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9540 DILEEN ST.
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78263
Mailing Address - Country:US
Mailing Address - Phone:210-643-6760
Mailing Address - Fax:
Practice Address - Street 1:9540 DILEEN ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78263-9625
Practice Address - Country:US
Practice Address - Phone:210-643-6760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX572418163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse