Provider Demographics
NPI:1730565284
Name:HARRIS, KENYETTA (PA-C)
Entity type:Individual
Prefix:
First Name:KENYETTA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 E WATER ST # 812
Mailing Address - Street 2:APT:20
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-1530
Mailing Address - Country:US
Mailing Address - Phone:267-629-1372
Mailing Address - Fax:
Practice Address - Street 1:132 THE MEADOWS DR
Practice Address - Street 2:
Practice Address - City:CENTRE HALL
Practice Address - State:PA
Practice Address - Zip Code:16828-9231
Practice Address - Country:US
Practice Address - Phone:814-634-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057725363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical