Basic Information
| Provider Information | |||||||||
| NPI: | 1801316153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENT | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | KATHLEEN BACK | ||||||||
| NamePrefix: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | BACK | ||||||||
| OtherFirstName: | LAUREL | ||||||||
| OtherMiddleName: | KATHLEEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 725 WELCH RD | ||||||||
| Address2: | |||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943041601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504978000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 770 WELCH RD | ||||||||
| Address2: | |||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943041511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504984069 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2017 | ||||||||
| LastUpdateDate: | 07/26/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95006802 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.