MEDICARE: KRYSTAL GLADSON KENNEDY FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	5013666	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	NNG706B	OTHER	NC	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598363681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL GLADSON KENNEDY FNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 603725
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-3725
Country	:	US
Telephone Number	:	828-575-2663
Fax Number	:	828-350-2174

Provider Business Practice Location Address
First Line	:	1150 E ARLINGTON BLVD
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27858-5866
Country	:	US
Telephone Number	:	252-756-1333
Fax Number	:	252-355-2068

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2020
Last Update Date	:	12/21/2023

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