Provider Demographics
NPI:1154302388
Name:KENNEDY, COLLEEN MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:MARIE
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 1:425 CENTRE VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3409
Mailing Address - Country:US
Mailing Address - Phone:859-341-3575
Mailing Address - Fax:859-341-5702
Practice Address - Street 1:425 CENTRE VIEW BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3409
Practice Address - Country:US
Practice Address - Phone:859-341-3575
Practice Address - Fax:859-341-5702
Is Sole Proprietor?:No
Enumeration Date:2005-11-05
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101536363AM0700X
KYPA1114363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100320670Medicaid
FL291895100Medicaid
OHKEPA29301Medicare PIN
FLE5137XMedicare ID - Type Unspecified
FL291895100Medicaid
KYK167380Medicare PIN