Provider Demographics
NPI:1073180352
Name:BELIZAIRE, KENSON
Entity type:Individual
Prefix:
First Name:KENSON
Middle Name:
Last Name:BELIZAIRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4777 CAPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-8186
Mailing Address - Country:US
Mailing Address - Phone:954-864-4191
Mailing Address - Fax:
Practice Address - Street 1:4777 CAPITAL DR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-8186
Practice Address - Country:US
Practice Address - Phone:954-864-4191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLAPRN11013409363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program