Provider Demographics
NPI:1164801965
Name:KENNEDY, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 DULLES DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3718
Mailing Address - Country:US
Mailing Address - Phone:337-991-9276
Mailing Address - Fax:337-991-9288
Practice Address - Street 1:2900 WESTFORK DR
Practice Address - Street 2:STE 401
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70827-0010
Practice Address - Country:US
Practice Address - Phone:337-991-9276
Practice Address - Fax:337-991-9288
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129413363LF0000X
LAAP08717363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily