Provider Demographics
NPI:1548504665
Name:BRANN, KENNETH DALE JR
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DALE
Last Name:BRANN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 W ILES AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4191
Mailing Address - Country:US
Mailing Address - Phone:636-284-4987
Mailing Address - Fax:
Practice Address - Street 1:2060 W ILES AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4191
Practice Address - Country:US
Practice Address - Phone:636-284-4987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3118237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3118OtherILLINOIS HEARING INSTRUMENT DISPENSER