Healthcare Provider Details

I. General information

NPI: 1811476302
Provider Name (Legal Business Name): KENNA M MEDLEY ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 TAMIAMI TRL N STE 220
NAPLES FL
34102-6233
US

IV. Provider business mailing address

130 TAMIAMI TRL N STE 220
NAPLES FL
34102-6233
US

V. Phone/Fax

Practice location:
  • Phone: 239-624-1700
  • Fax: 239-434-8605
Mailing address:
  • Phone: 239-624-1700
  • Fax: 239-434-8605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9318214
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9318214
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: