Healthcare Provider Details

I. General information

NPI: 1194898155
Provider Name (Legal Business Name): STACIA KENET MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 THOMAS DR
MILL VALLEY CA
94941
US

IV. Provider business mailing address

10 THOMAS DR
MILL VALLEY CA
94941
US

V. Phone/Fax

Practice location:
  • Phone: 415-380-8448
  • Fax: 415-380-8673
Mailing address:
  • Phone: 415-380-8448
  • Fax: 415-380-8673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG070541
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: