Provider Demographics
NPI:1114549185
Name:KENNIMER, TINA (NP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:KENNIMER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 KENNEDALE SUBLETT RD
Mailing Address - Street 2:
Mailing Address - City:KENNEDALE
Mailing Address - State:TX
Mailing Address - Zip Code:76060-5821
Mailing Address - Country:US
Mailing Address - Phone:682-429-2723
Mailing Address - Fax:
Practice Address - Street 1:1115 KENNEDALE SUBLETT RD
Practice Address - Street 2:
Practice Address - City:KENNEDALE
Practice Address - State:TX
Practice Address - Zip Code:76060-5821
Practice Address - Country:US
Practice Address - Phone:682-429-2723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP146035363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily