Healthcare Provider Details

I. General information

NPI: 1376529677
Provider Name (Legal Business Name): ANN JEANETTE KENWORTHY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 MAIN ST SUITE 100
PLACERVILLE CA
95667-5736
US

IV. Provider business mailing address

1100 MARSHALL WAY
PLACERVILLE CA
95667-6533
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-2990
  • Fax: 530-626-2992
Mailing address:
  • Phone: 530-626-2990
  • Fax: 530-626-2992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number476129
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: