Provider Demographics
NPI:1871808337
Name:DAVID, KENNETH A JR (RN)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:DAVID
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4106 MIDDLEBURY CT
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-3262
Mailing Address - Country:US
Mailing Address - Phone:410-255-8945
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD STE 240
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-2225
Practice Address - Country:US
Practice Address - Phone:410-255-8945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR169372163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse