Provider Demographics
NPI:1508573353
Name:KENNELLY, MICHAEL STEVEN (CRNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEVEN
Last Name:KENNELLY
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 HOSPITAL AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1463
Mailing Address - Country:US
Mailing Address - Phone:814-375-3015
Mailing Address - Fax:
Practice Address - Street 1:145 HOSPITAL AVE STE 113
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1463
Practice Address - Country:US
Practice Address - Phone:814-375-3015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP026537207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP026537OtherPENNSYLVANIA STATE NURSE PRACTITIONER LICENSE