Healthcare Provider Details

I. General information

NPI: 1073880498
Provider Name (Legal Business Name): COLLEEN A KENNELLY N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 E FORDHAM RD
BRONX NY
10458-5149
US

IV. Provider business mailing address

13 WAINWRIGHT ST
RYE NY
10580-3711
US

V. Phone/Fax

Practice location:
  • Phone: 718-817-4160
  • Fax:
Mailing address:
  • Phone: 914-967-4971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF336652-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: