Provider Demographics
NPI:1184297293
Name:KENNEL, MARISA JOY (CRNP)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:JOY
Last Name:KENNEL
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:810 SIR THOMAS CT STE 101
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4839
Mailing Address - Country:US
Mailing Address - Phone:717-614-4420
Mailing Address - Fax:
Practice Address - Street 1:810 SIR THOMAS CT
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-4839
Practice Address - Country:US
Practice Address - Phone:717-614-4420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN696220163W00000X
PASP024131363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse