Provider Demographics
NPI:1598363681
Name:KENNEDY, KRYSTAL GLADSON (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:GLADSON
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:LYNN
Other - Last Name:GLADSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2663
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:1150 E ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5866
Practice Address - Country:US
Practice Address - Phone:252-756-1333
Practice Address - Fax:252-355-2068
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5013666363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1598363681Medicaid
NCNNG706BOtherMEDICARE PTAN