Provider Demographics
NPI:1316160914
Name:KENNELLY, NANETTE S (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:NANETTE
Middle Name:S
Last Name:KENNELLY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-0746
Mailing Address - Country:US
Mailing Address - Phone:701-364-5433
Mailing Address - Fax:701-364-2256
Practice Address - Street 1:1220 MAIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8201
Practice Address - Country:US
Practice Address - Phone:701-364-5433
Practice Address - Fax:701-364-2256
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND664235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND26042OtherND BCBS
ND50906Medicaid