Provider Demographics
NPI:1841522927
Name:KENNEALLY, BONNY (LPN)
Entity type:Individual
Prefix:
First Name:BONNY
Middle Name:
Last Name:KENNEALLY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6847 W CARTER RD
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-1331
Mailing Address - Country:US
Mailing Address - Phone:315-533-0848
Mailing Address - Fax:
Practice Address - Street 1:6847 W CARTER RD
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-1331
Practice Address - Country:US
Practice Address - Phone:315-533-0848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-01
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113890-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01705682Medicaid