Basic Information
| Provider Information | |||||||||
| NPI: | 1841810371 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEMBU | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 N MALACATE ST | ||||||||
| Address2: | |||||||||
| City: | AJO | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853212254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203875651 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13060 S SUNLAND GIN RD | ||||||||
| Address2: | |||||||||
| City: | ARIZONA CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851238448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203875651 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2020 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 240670 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 240670 | 01 | 240670 | OTHER |