Provider Demographics
NPI:1073167953
Name:KENNEDY, KENNA LYN (PMHNP)
Entity Type:Individual
Prefix:
First Name:KENNA
Middle Name:LYN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 N LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-7111
Mailing Address - Country:US
Mailing Address - Phone:605-322-2982
Mailing Address - Fax:
Practice Address - Street 1:4500 N LEWIS AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-7111
Practice Address - Country:US
Practice Address - Phone:605-322-2982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001616363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health