Provider Demographics
NPI:1114742509
Name:STMARC, KENNY
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:STMARC
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 1:337 FAULKNER DR
Mailing Address - Street 2:
Mailing Address - City:LITHOPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:43136-7519
Mailing Address - Country:US
Mailing Address - Phone:845-598-3559
Mailing Address - Fax:
Practice Address - Street 1:337 FAULKNER DR
Practice Address - Street 2:
Practice Address - City:LITHOPOLIS
Practice Address - State:OH
Practice Address - Zip Code:43136-7519
Practice Address - Country:US
Practice Address - Phone:845-598-3559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.174786.MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse