Provider Demographics
NPI:1083677124
Name:NUNNERY, KENNETH EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EDWARD
Last Name:NUNNERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2362
Mailing Address - Country:US
Mailing Address - Phone:803-547-7541
Mailing Address - Fax:803-548-0122
Practice Address - Street 1:1690 HIGHWAY 160 W
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8024
Practice Address - Country:US
Practice Address - Phone:803-547-7541
Practice Address - Fax:803-548-0122
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7482207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC074822Medicaid
SCB919378371Medicare PIN
SC074822Medicaid
SCB919378371Medicare ID - Type Unspecified