Provider Demographics
NPI:1114231503
Name:KENNEDY, KYLE LOGAN (NP-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:LOGAN
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:KYLE
Other - Middle Name:LOGAN
Other - Last Name:DEXHEIMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:ONE VETERANS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417
Mailing Address - Country:US
Mailing Address - Phone:612-467-4100
Mailing Address - Fax:612-870-5491
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 423 S
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:612-871-1145
Practice Address - Fax:612-870-5491
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA0710079363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner