Provider Demographics
NPI:1811681497
Name:TAKEDA, KERRY L (APRN)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:L
Last Name:TAKEDA
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8074 S 84TH ST
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-3303
Mailing Address - Country:US
Mailing Address - Phone:402-779-7207
Mailing Address - Fax:402-779-7210
Practice Address - Street 1:8074 S 84TH ST
Practice Address - Street 2:
Practice Address - City:LA VISTA
Practice Address - State:NE
Practice Address - Zip Code:68128-3303
Practice Address - Country:US
Practice Address - Phone:402-779-7207
Practice Address - Fax:402-779-7210
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE114804363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10028073900Medicaid