Provider Demographics
NPI:1154409332
Name:KENEALY, DIANE (RN NNP)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:KENEALY
Suffix:
Gender:F
Credentials:RN NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E OLNEY AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2470
Mailing Address - Country:US
Mailing Address - Phone:215-456-1825
Mailing Address - Fax:215-456-5926
Practice Address - Street 1:5501 OLD YORK RD # PALEY1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3018
Practice Address - Country:US
Practice Address - Phone:215-456-7170
Practice Address - Fax:215-456-4923
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN09780100363LN0005X
PASP012130363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1038803330002Medicaid