Provider Demographics
NPI:1841227469
Name:SPEICHER, KENNETH J (CRNA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:SPEICHER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10624 BRYONY CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-8751
Mailing Address - Country:US
Mailing Address - Phone:704-708-9017
Mailing Address - Fax:
Practice Address - Street 1:CAROLINAS MEDICAL CENTER-PINEVILLE
Practice Address - Street 2:10628 PARK ROAD
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210
Practice Address - Country:US
Practice Address - Phone:704-667-1000
Practice Address - Fax:704-667-0409
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC175891367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051738Medicaid
NC2600208Medicare ID - Type Unspecified