MEDICARE: BONNIE KENNEDY, APRN, BC, P.A.

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	101YM0800X	Mental Health Counselor	090018 (RN)	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	090018	OTHER	NC	RN LICENSE #

General Provider Information

NPI Number	:	1235319914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONNIE KENNEDY, APRN, BC, P.A.

Provider Business Mailing Address
First Line	:	3518 DRAWBRIDGE PKWY
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27410-8432
Country	:	US
Telephone Number	:	336-209-3568
Fax Number	:	336-209-3568

Provider Business Practice Location Address
First Line	:	3518 DRAWBRIDGE PKWY
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27410-8432
Country	:	US
Telephone Number	:	336-209-3568
Fax Number	:	336-209-3568

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BONNIE KENNEDY
Credential	:	MSN,APRN,BC
Telephone Number	:	336-209-3568

Provider Enumeration Date	:	11/09/2007
Last Update Date	:	03/19/2010

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