Provider Demographics
NPI:1881650885
Name:KENNY, LAURA CANCILLA (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:CANCILLA
Last Name:KENNY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 CAVALRY DR.
Mailing Address - Street 2:STE 102
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042
Mailing Address - Country:US
Mailing Address - Phone:859-817-9772
Mailing Address - Fax:859-817-9885
Practice Address - Street 1:1515 CAVALRY DR.
Practice Address - Street 2:STE 102
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042
Practice Address - Country:US
Practice Address - Phone:859-817-9772
Practice Address - Fax:859-817-9885
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43946207RA0401X
OH35-086281207R00000X
OH35.086281207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00224928OtherRAIL ROAD MEDICARE
IN200523050Medicaid
OH2594581Medicaid
KY6410106600Medicaid
IN200523050Medicaid
OHKE4162931Medicare PIN