Provider Demographics
NPI:1427710789
Name:PORTES, KENNETH O (RN)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:O
Last Name:PORTES
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4378 AUBURN BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-4175
Mailing Address - Country:US
Mailing Address - Phone:279-348-7200
Mailing Address - Fax:279-348-7201
Practice Address - Street 1:4378 AUBURN BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-4175
Practice Address - Country:US
Practice Address - Phone:279-348-7200
Practice Address - Fax:279-348-7201
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95208847163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse