Healthcare Provider Details

I. General information

NPI: 1104927029
Provider Name (Legal Business Name): GLEN ALAN KENOSKI ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW US VETERANS RD
PORTLAND OR
97207
US

IV. Provider business mailing address

1819 NE 66TH ST
VANCOUVER WA
98665-0367
US

V. Phone/Fax

Practice location:
  • Phone: 503-220-8262
  • Fax: 360-737-1419
Mailing address:
  • Phone: 360-737-8986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number088006537N3
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: