=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356385082
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH WAYNE NORDLUND N.P
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2006
-----------------------------------------------------
Last Update Date | 11/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 58581 US HIGHWAY 371 STE F, G, H
-----------------------------------------------------
City | ANZA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92539-9331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-763-4759
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1695 N SUNRISE WAY
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92262-3701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-323-2118
-----------------------------------------------------
Fax | 510-879-9100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN428808
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | NPF10271
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------