Provider Demographics
NPI:1922008432
Name:KENNEDY, BONNIE M (CRNA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:M
Last Name:KENNEDY
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 1:6555 BARRIER GEORGEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-8400
Mailing Address - Country:US
Mailing Address - Phone:706-431-1097
Mailing Address - Fax:
Practice Address - Street 1:8201 HEALTHCARE LOOP
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-7072
Practice Address - Country:US
Practice Address - Phone:980-302-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC60662367500000X
NC1753367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ31025Medicare UPIN