Healthcare Provider Details

I. General information

NPI: 1609459080
Provider Name (Legal Business Name): BIANCA NICOLE KENNEL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 W CHARLESTON BLVD # 150
LAS VEGAS NV
89102-1998
US

IV. Provider business mailing address

9033 W SAHARA AVE
LAS VEGAS NV
89117-5745
US

V. Phone/Fax

Practice location:
  • Phone: 702-476-9999
  • Fax: 702-946-1343
Mailing address:
  • Phone: 702-476-9999
  • Fax: 702-946-1343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2718
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: