Provider Demographics
NPI:1699593699
Name:KENNERLY, MACEY MCSWAIN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MACEY
Middle Name:MCSWAIN
Last Name:KENNERLY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 UNION RD STE A
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2201
Mailing Address - Country:US
Mailing Address - Phone:704-867-6188
Mailing Address - Fax:704-866-4437
Practice Address - Street 1:1530 UNION RD STE A
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2201
Practice Address - Country:US
Practice Address - Phone:704-867-6188
Practice Address - Fax:704-866-4437
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC292152163W00000X
NC2020042132363LP0808X
NC5021152363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse