Provider Demographics
NPI:1790917599
Name:CROMWELL, KENALYN M (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KENALYN
Middle Name:M
Last Name:CROMWELL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 KRISTANNA DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3278
Mailing Address - Country:US
Mailing Address - Phone:850-252-2628
Mailing Address - Fax:850-215-7809
Practice Address - Street 1:230 FOREST PARK CIR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4919
Practice Address - Country:US
Practice Address - Phone:850-481-0419
Practice Address - Fax:850-215-7809
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2015-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3082235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884259100Medicaid