MEDICARE: KELLY NICOLE KENIRAY CNP

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	363LF0000X	Family Nurse Practitioner	APRN.CNP.021986	OH

General Provider Information

NPI Number	:	1427560440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY NICOLE KENIRAY CNP

Provider Business Mailing Address
First Line	:	629 47TH ST NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44709
Country	:	UM
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 15TH ST NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44703-1704
Country	:	US
Telephone Number	:	330-450-0800
Fax Number	:

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

Provider Enumeration Date	:	10/31/2017
Last Update Date	:	10/31/2017

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