Healthcare Provider Details

I. General information

NPI: 1003332909
Provider Name (Legal Business Name): KENN RAFANAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ROSECRANS AVE # 3230
EL SEGUNDO CA
90245-4749
US

IV. Provider business mailing address

1723 BONANZA AVE
SIMI VALLEY CA
93063-5803
US

V. Phone/Fax

Practice location:
  • Phone: 323-628-8671
  • Fax:
Mailing address:
  • Phone: 18187302452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95006905
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: