Provider Demographics
NPI:1609459080
Name:KENNEL, BIANCA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:NICOLE
Last Name:KENNEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 W CHARLESTON BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1998
Mailing Address - Country:US
Mailing Address - Phone:702-476-9999
Mailing Address - Fax:
Practice Address - Street 1:6990 SMOKE RANCH RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-3119
Practice Address - Country:US
Practice Address - Phone:702-476-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PA2718363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program