Provider Demographics
NPI:1649583113
Name:MCKENNEY, KIMBERLY A (FNP-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:MCKENNEY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 REMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4725
Mailing Address - Country:US
Mailing Address - Phone:704-834-4390
Mailing Address - Fax:704-834-3274
Practice Address - Street 1:2240 REMOUNT RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4725
Practice Address - Country:US
Practice Address - Phone:704-834-4390
Practice Address - Fax:704-834-3274
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004789363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP01182484OtherMEDICARE RR
NC16854OtherBCBS NC
NC1649583113Medicaid
NC1649583113Medicaid