Healthcare Provider Details

I. General information

NPI: 1306233523
Provider Name (Legal Business Name): KRISTINE KENNING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2015
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CANAL RD
MASSAPEQUA NY
11758-6617
US

IV. Provider business mailing address

1250 E MARSHALL ST
RICHMOND VA
23298-5051
US

V. Phone/Fax

Practice location:
  • Phone: 203-907-7151
  • Fax: 804-828-0191
Mailing address:
  • Phone: 804-828-7391
  • Fax: 804-828-0191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number315637-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: