Provider Demographics
NPI:1659333078
Name:KENNGOTT, CAROLYN FRANCES (CRNA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:FRANCES
Last Name:KENNGOTT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 N FORBES BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1412
Mailing Address - Country:US
Mailing Address - Phone:520-872-7536
Mailing Address - Fax:520-872-7929
Practice Address - Street 1:1171 W TARGET RANGE RD
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-2415
Practice Address - Country:US
Practice Address - Phone:520-285-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0689367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ599761Medicaid
AZZ145034OtherMEDICARE PTAN
AZ599761Medicaid