Provider Demographics
NPI:1407483530
Name:KENNERLY, SALLY ANN
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:KENNERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BLUEBELL AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-3906
Mailing Address - Country:US
Mailing Address - Phone:843-926-9382
Mailing Address - Fax:
Practice Address - Street 1:300 BLUEBELL AVE
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-3906
Practice Address - Country:US
Practice Address - Phone:843-926-9382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide