Provider Demographics
NPI:1194875989
Name:BARAJAS, KENNY
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:BARAJAS
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 1:14721 TRIADELPHIA RD
Mailing Address - Street 2:
Mailing Address - City:GLENELG
Mailing Address - State:MD
Mailing Address - Zip Code:21737-9409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14721 TRIADELPHIA RD
Practice Address - Street 2:
Practice Address - City:GLENELG
Practice Address - State:MD
Practice Address - Zip Code:21737-9409
Practice Address - Country:US
Practice Address - Phone:443-266-7029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR134988163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse