Provider Demographics
NPI:1730419870
Name:DEMOTT, KENNETH EDWARD (FNP)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:EDWARD
Last Name:DEMOTT
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:MR
Other - First Name:KENNETH
Other - Middle Name:EDWARD
Other - Last Name:DEMOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:39 PEARL ST W
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:NY
Mailing Address - Zip Code:13838-1330
Mailing Address - Country:US
Mailing Address - Phone:607-561-2021
Mailing Address - Fax:607-563-2663
Practice Address - Street 1:39 PEARL ST W
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:NY
Practice Address - Zip Code:13838-1330
Practice Address - Country:US
Practice Address - Phone:607-561-2021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-13
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336161363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily