Provider Demographics
NPI:1154374478
Name:KENNEDY, BONNIE (APRN, BC, PA)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:APRN, BC, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3518 DRAWBRIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-8432
Mailing Address - Country:US
Mailing Address - Phone:336-209-3568
Mailing Address - Fax:336-540-1095
Practice Address - Street 1:3518 DRAWBRIDGE PKWY
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-8432
Practice Address - Country:US
Practice Address - Phone:336-209-3568
Practice Address - Fax:336-540-1095
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC090018364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2598961BMedicare ID - Type Unspecified