Provider Demographics
NPI:1437746245
Name:KENNERLY, CHARLOTTE (INDEPENDENT PROVIDER)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:KENNERLY
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16912 GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-1554
Mailing Address - Country:US
Mailing Address - Phone:216-965-3460
Mailing Address - Fax:
Practice Address - Street 1:16912 GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-1554
Practice Address - Country:US
Practice Address - Phone:216-965-3460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1831304376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1831304Medicaid