Provider Demographics
NPI:1083608780
Name:KENNEDY, MARY M (RN, NP, CNM)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:M
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RN, NP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 STONERIDGE DR
Mailing Address - Street 2:THE PERMANENTE MEDICAL GROUP
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-4501
Mailing Address - Country:US
Mailing Address - Phone:925-847-5629
Mailing Address - Fax:925-847-5148
Practice Address - Street 1:7601 STONERIDGE DR
Practice Address - Street 2:THE PERMANENTE MEDICAL GROUP
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-4501
Practice Address - Country:US
Practice Address - Phone:925-847-5629
Practice Address - Fax:925-847-5148
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA177602363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA177602OtherRN LICENSE NUMBER
CAP16645Medicare UPIN