MEDICARE: MARISA JOY KENNEL CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN696220	PA
2	363LF0000X	Family Nurse Practitioner	SP024131	PA

General Provider Information

NPI Number	:	1184297293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA JOY KENNEL CRNP

Provider Business Mailing Address
First Line	:	810 SIR THOMAS CT STE 101
Second Line	:
City	:	HARRISBURG
State	:	PA
Zip	:	17109-4839
Country	:	US
Telephone Number	:	717-614-4420
Fax Number	:

Provider Business Practice Location Address
First Line	:	810 SIR THOMAS CT
Second Line	:
City	:	HARRISBURG
State	:	PA
Zip	:	17109-4839
Country	:	US
Telephone Number	:	717-614-4420
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2021
Last Update Date	:	02/19/2026

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