Provider Demographics
NPI:1063483774
Name:AGNELLO, KERRY (DO)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:
Last Name:AGNELLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4-1830 NORMANDY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-907-6186
Mailing Address - Fax:
Practice Address - Street 1:4-1830 NORMANDY DRIVE
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-6186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07942900207Q00000X
NC2011-01723207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ095009Medicare ID - Type Unspecified
I42978Medicare UPIN