=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801456652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH GARRETT HONKOMP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2019
-----------------------------------------------------
Last Update Date | 06/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 MAY ST
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-1622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-229-4463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 309 MAY ST
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-1622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-229-4463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164X00000X
-----------------------------------------------------
Taxonomy Name | Licensed Vocational Nurse
-----------------------------------------------------
License Number | 330741
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------