Healthcare Provider Details

I. General information

NPI: 1245575315
Provider Name (Legal Business Name): KENNETH LEE CRAFT JR. FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2012
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 COUNTRY ESTATES CIR STE 111
RENO NV
89511-4017
US

IV. Provider business mailing address

3983 S MCCARRAN BLVD # 703
RENO NV
89502-7510
US

V. Phone/Fax

Practice location:
  • Phone: 775-400-6617
  • Fax: 775-418-6100
Mailing address:
  • Phone: 775-400-6617
  • Fax: 775-418-6100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number726633
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number726633
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22618
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number001840
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: