Healthcare Provider Details

I. General information

NPI: 1013584655
Provider Name (Legal Business Name): KENNETH GRIFFIN RN WCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SILVERCREST DR
NEW ALBANY IN
47150-7800
US

IV. Provider business mailing address

117 MEADOW DR
SELLERSBURG IN
47172-9785
US

V. Phone/Fax

Practice location:
  • Phone: 812-542-6720
  • Fax:
Mailing address:
  • Phone: 502-718-1612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28208427A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: