Provider Demographics
NPI:1962168468
Name:AMANZE, KENNY ADESHOLA (CRNP-PHM)
Entity type:Individual
Prefix:MS
First Name:KENNY
Middle Name:ADESHOLA
Last Name:AMANZE
Suffix:
Gender:F
Credentials:CRNP-PHM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 BAIKAL LOOP
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-7051
Mailing Address - Country:US
Mailing Address - Phone:240-643-5160
Mailing Address - Fax:
Practice Address - Street 1:2409 BAIKAL LOOP
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-7051
Practice Address - Country:US
Practice Address - Phone:240-643-5160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR207092363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1043645344Medicaid
MD1083094056Medicaid