Healthcare Provider Details

I. General information

NPI: 1457713794
Provider Name (Legal Business Name): ROBERT LEE KENT JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 EAST WINROW AVENUE
FORT HUACHUCA AZ
85613
US

IV. Provider business mailing address

657 HAYES DR
SIERRA VISTA AZ
85635-4448
US

V. Phone/Fax

Practice location:
  • Phone: 520-533-9026
  • Fax:
Mailing address:
  • Phone: 915-243-3753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN119404
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: