Healthcare Provider Details

I. General information

NPI: 1699593699
Provider Name (Legal Business Name): MACEY MCSWAIN KENNERLY PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1089 X RAY DR
GASTONIA NC
28054-7489
US

IV. Provider business mailing address

1089 X RAY DR
GASTONIA NC
28054-7489
US

V. Phone/Fax

Practice location:
  • Phone: 828-707-0409
  • Fax: 833-917-0055
Mailing address:
  • Phone: 828-707-0409
  • Fax: 833-917-0055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2020042132
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number292152
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5021152
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: