Provider Demographics
NPI:1699532416
Name:NGUYEN, KENNY TRAN (COTA/L)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:TRAN
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 LONGVIEW AVE SW APT 1
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-1532
Mailing Address - Country:US
Mailing Address - Phone:540-353-4700
Mailing Address - Fax:
Practice Address - Street 1:2521 LONGVIEW AVE SW APT 1
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1532
Practice Address - Country:US
Practice Address - Phone:540-353-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002765224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant