Healthcare Provider Details

I. General information

NPI: 1811542186
Provider Name (Legal Business Name): ANDREA MARIE LADOW-KENNY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 CAPRICORN WAY STE 207
SANTA ROSA CA
95407-5486
US

IV. Provider business mailing address

2225 CHALLENGER WAY
SANTA ROSA CA
95407-5441
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-8181
  • Fax:
Mailing address:
  • Phone: 707-576-8181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number766952
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: