1013169234 NPI number — MRS. MICHELE CONSTANCE KENNY CRNA

Table of content: MRS. MICHELE CONSTANCE KENNY CRNA (NPI 1013169234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013169234 NPI number — MRS. MICHELE CONSTANCE KENNY CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNY
Provider First Name:
MICHELE
Provider Middle Name:
CONSTANCE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MORA
Provider Other First Name:
MICHELE
Provider Other Middle Name:
CONSTANCE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013169234
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
164 LAKE RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06488-4161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-264-9110
Provider Business Mailing Address Fax Number:
203-841-1252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
164 LAKE RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06488-4161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-264-9110
Provider Business Practice Location Address Fax Number:
203-841-1252
Provider Enumeration Date:
10/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  004084 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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