Healthcare Provider Details

I. General information

NPI: 1467988451
Provider Name (Legal Business Name): MICHAEL KENNY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8350 RIVERWALK PARK BLVD STE 1
FORT MYERS FL
33919-8759
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-9696
  • Fax: 239-343-4198
Mailing address:
  • Phone: 239-343-9696
  • Fax: 239-343-4198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008191
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9121142
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: