Healthcare Provider Details

I. General information

NPI: 1205821493
Provider Name (Legal Business Name): MARIA S KENNEALLY APNP, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 E. WARNER RD. SUITE 107
GILBERT AZ
85296-3073
US

IV. Provider business mailing address

652 E WARNER RD STE 107
GILBERT AZ
85296-3073
US

V. Phone/Fax

Practice location:
  • Phone: 608-345-7956
  • Fax:
Mailing address:
  • Phone: 480-539-8680
  • Fax: 480-539-1763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP8296
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: