MEDICARE: MR. KENNY CHARLES NALL MD

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	207RP1001X	Pulmonary Disease Physician	9901269	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1253W	OTHER	NC	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710961727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNY CHARLES NALL MD

Provider Business Mailing Address
First Line	:	628 E 12TH ST
Second Line	:
City	:	WASHINGTON
State	:	NC
Zip	:	27889-3409
Country	:	US
Telephone Number	:	252-974-9361
Fax Number	:	252-974-9115

Provider Business Practice Location Address
First Line	:	628 E 12TH ST
Second Line	:
City	:	WASHINGTON
State	:	NC
Zip	:	27889-3409
Country	:	US
Telephone Number	:	252-974-9361
Fax Number	:	252-974-9115

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

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	01/06/2022

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