Provider Demographics
NPI:1164502290
Name:KENNEDY, BRENDA A (APN)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:A
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442-0910
Mailing Address - Country:US
Mailing Address - Phone:870-561-3300
Mailing Address - Fax:870-561-3307
Practice Address - Street 1:434 HWY 18 BYPASS
Practice Address - Street 2:
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442
Practice Address - Country:US
Practice Address - Phone:870-561-3300
Practice Address - Fax:870-561-3307
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01337363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARS69760Medicare UPIN
AR5U191Medicare ID - Type Unspecified