Healthcare Provider Details

I. General information

NPI: 1376852772
Provider Name (Legal Business Name): KEVIN MICHAEL KNACK JR. N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2010
Last Update Date: 09/02/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 REDWOOD HWY FRONTAGE RD STE 240
MILL VALLEY CA
94941-3055
US

IV. Provider business mailing address

655 REDWOOD HWY FRONTAGE RD STE 240
MILL VALLEY CA
94941-3055
US

V. Phone/Fax

Practice location:
  • Phone: 866-247-4292
  • Fax: 866-247-4292
Mailing address:
  • Phone: 866-247-4292
  • Fax: 866-247-4292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95014679
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60313580
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95014679
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60313579
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: