Healthcare Provider Details

I. General information

NPI: 1427603794
Provider Name (Legal Business Name): KENNETH VICTOR COLLINS ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 FAIRMOUNT AVE
FORT WORTH TX
76104-4215
US

IV. Provider business mailing address

601 OMEGA DR STE 208
ARLINGTON TX
76014-2075
US

V. Phone/Fax

Practice location:
  • Phone: 817-335-5288
  • Fax:
Mailing address:
  • Phone: 817-465-5881
  • Fax: 817-465-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP142526
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP142526
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: