Provider Demographics
NPI:1558156257
Name:KENNERLY, ANGELA (RN)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:KENNERLY
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17401 126TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3313
Mailing Address - Country:US
Mailing Address - Phone:347-970-9663
Mailing Address - Fax:
Practice Address - Street 1:17401 126TH AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-3313
Practice Address - Country:US
Practice Address - Phone:347-970-9663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-12
Last Update Date:2025-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC210514163W00000X
NY436416-1163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163W00000XNursing Service ProvidersRegistered Nurse