Provider Demographics
NPI:1710961727
Name:NALL, KENNY CHARLES (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNY
Middle Name:CHARLES
Last Name:NALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3409
Mailing Address - Country:US
Mailing Address - Phone:252-974-9361
Mailing Address - Fax:252-974-9115
Practice Address - Street 1:628 E 12TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3409
Practice Address - Country:US
Practice Address - Phone:252-974-9361
Practice Address - Fax:252-974-9115
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901269207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1253WOtherBCBS
NC891253WMedicaid
NC891253WMedicaid
NC2342340Medicare ID - Type Unspecified