Provider Demographics
NPI:1144901398
Name:KENYENSO, IRENE
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:KENYENSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13045 WOODCUTTER CIR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876
Mailing Address - Country:US
Mailing Address - Phone:808-797-7585
Mailing Address - Fax:
Practice Address - Street 1:13045 WOODCUTTER CIR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876
Practice Address - Country:US
Practice Address - Phone:808-797-7585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR202216363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily