Healthcare Provider Details

I. General information

NPI: 1609872480
Provider Name (Legal Business Name): ROBERT J. MCKENNETT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2005
Last Update Date: 01/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S STATE ST DEPT OF ANES
DOVER DE
19901-3530
US

IV. Provider business mailing address

640 S. STATE STREET, POB 3RD FLOOR
DOVER DE
19901
US

V. Phone/Fax

Practice location:
  • Phone: 302-744-7088
  • Fax: 302-744-6407
Mailing address:
  • Phone: 302-480-1688
  • Fax: 302-480-9807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberL1-0034455 / L6-0A00
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: