Healthcare Provider Details

I. General information

NPI: 1275057911
Provider Name (Legal Business Name): MICHAEL KENNETH MCKENERY MSN, CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 PULLMAN SQ STE 255
BUTLER PA
16001-5654
US

IV. Provider business mailing address

150 WINDWOOD DR
WEXFORD PA
15090-8502
US

V. Phone/Fax

Practice location:
  • Phone: 724-431-4170
  • Fax:
Mailing address:
  • Phone: 760-505-5523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN697852
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP017670
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: