Basic Information
| Provider Information | |||||||||
| NPI: | 1932596632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEMER | ||||||||
| FirstName: | ANGELEIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 185 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | SAINT HELENS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970511535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033664540 | ||||||||
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| Practice Location | |||||||||
| Address1: | 185 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | SAINT HELENS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970511535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033664540 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2015 | ||||||||
| LastUpdateDate: | 04/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 201402811RN | OR | Y | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
No ID Information.