Provider Demographics
NPI:1528531274
Name:REDON, KENNETH ADRIAN BLANCO (FNP)
Entity type:Individual
Prefix:MR
First Name:KENNETH ADRIAN
Middle Name:BLANCO
Last Name:REDON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 RINCONADA DR APT 14
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-2827
Mailing Address - Country:US
Mailing Address - Phone:415-964-7441
Mailing Address - Fax:
Practice Address - Street 1:5400 ALDRIN CT
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93313-2103
Practice Address - Country:US
Practice Address - Phone:661-489-5999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-05
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ219805363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily