Healthcare Provider Details

I. General information

NPI: 1922008432
Provider Name (Legal Business Name): BONNIE M KENNEDY C.R.N.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 HEALTHCARE LOOP
CHARLOTTE NC
28215-7072
US

IV. Provider business mailing address

6555 BARRIER GEORGEVILLE RD
CONCORD NC
28025-8400
US

V. Phone/Fax

Practice location:
  • Phone: 980-302-1000
  • Fax:
Mailing address:
  • Phone: 706-431-1097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number60662
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1753
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: