Provider Demographics
NPI:1891586202
Name:PAUL, KENNIS
Entity type:Individual
Prefix:
First Name:KENNIS
Middle Name:
Last Name:PAUL
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 1:5200 BANCROFT AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-4414
Mailing Address - Country:US
Mailing Address - Phone:803-979-4873
Mailing Address - Fax:
Practice Address - Street 1:5200 BANCROFT AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-4414
Practice Address - Country:US
Practice Address - Phone:803-979-4873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEH13681965172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver