Healthcare Provider Details

I. General information

NPI: 1356385082
Provider Name (Legal Business Name): KENNETH WAYNE NORDLUND N.P
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58581 US HIGHWAY 371 STE F, G, H
ANZA CA
92539-9331
US

IV. Provider business mailing address

1695 N SUNRISE WAY
PALM SPRINGS CA
92262-3701
US

V. Phone/Fax

Practice location:
  • Phone: 951-763-4759
  • Fax:
Mailing address:
  • Phone: 760-323-2118
  • Fax: 510-879-9100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN428808
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNPF10271
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: