Healthcare Provider Details

I. General information

NPI: 1881650885
Provider Name (Legal Business Name): LAURA CANCILLA KENNY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 CAVALRY DR. STE 102
FLORENCE KY
41042
US

IV. Provider business mailing address

1515 CAVALRY DR. STE 102
FLORENCE KY
41042
US

V. Phone/Fax

Practice location:
  • Phone: 859-817-9772
  • Fax: 859-817-9885
Mailing address:
  • Phone: 859-817-9772
  • Fax: 859-817-9885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number43946
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-086281
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number35.086281
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: