Provider Demographics
NPI:1114168705
Name:KENNEDY, DANI B (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DANI
Middle Name:B
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 FM 1764 RD
Mailing Address - Street 2:STE 190
Mailing Address - City:LA MARQUE
Mailing Address - State:TX
Mailing Address - Zip Code:77568-2826
Mailing Address - Country:US
Mailing Address - Phone:409-744-4030
Mailing Address - Fax:409-740-4187
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-1250
Practice Address - Country:US
Practice Address - Phone:409-744-4030
Practice Address - Fax:409-740-4187
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06064363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX851N99OtherBCBSTX
TX8L15502Medicare PIN