Provider Demographics
NPI:1982442380
Name:SOTO BALBUENA, KENLLY J
Entity type:Individual
Prefix:
First Name:KENLLY
Middle Name:J
Last Name:SOTO BALBUENA
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 1:2478 SIMONELLI DR
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08361-7748
Mailing Address - Country:US
Mailing Address - Phone:609-579-3477
Mailing Address - Fax:
Practice Address - Street 1:2478 SIMONELLI DR
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08361-7748
Practice Address - Country:US
Practice Address - Phone:609-579-3477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15083500363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily