Provider Demographics
NPI:1093187734
Name:KENNEDY, BONNIE SUE (NP)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:SUE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:1809 WADE HAMPTON BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-4041
Practice Address - Country:US
Practice Address - Phone:864-522-5000
Practice Address - Fax:864-241-9275
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19511363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3552Medicaid
SCNP3552Medicaid