Provider Demographics
NPI:1013169234
Name:KENNY, MICHELE CONSTANCE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:CONSTANCE
Last Name:KENNY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:MICHELE
Other - Middle Name:CONSTANCE
Other - Last Name:MORA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:164 LAKE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-4161
Mailing Address - Country:US
Mailing Address - Phone:203-264-9110
Mailing Address - Fax:203-841-1252
Practice Address - Street 1:164 LAKE RIDGE RD
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-4161
Practice Address - Country:US
Practice Address - Phone:203-264-9110
Practice Address - Fax:203-841-1252
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004084367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered