Provider Demographics
NPI:1285395806
Name:IGWACHO, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:IGWACHO
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 1:3515 CENTURY AVE N APT 201B
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5667
Mailing Address - Country:US
Mailing Address - Phone:651-424-7922
Mailing Address - Fax:
Practice Address - Street 1:3515 CENTURY AVE N APT 201B
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-5667
Practice Address - Country:US
Practice Address - Phone:651-424-7922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2491231163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse