Healthcare Provider Details

I. General information

NPI: 1265955363
Provider Name (Legal Business Name): KENEIL EDMOND CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WOODS RD
VALHALLA NY
10595-1530
US

IV. Provider business mailing address

19 BRADHURST AVE STE 3100N
HAWTHORNE NY
10532-2140
US

V. Phone/Fax

Practice location:
  • Phone: 914-493-7000
  • Fax: 914-493-7927
Mailing address:
  • Phone: 914-909-9018
  • Fax: 914-909-9028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number604621-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number118587
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: