Provider Demographics
NPI:1235196304
Name:KENNEDY, SARA ELLEN (RNC)
Entity Type:Individual
Prefix:MS
First Name:SARA
Middle Name:ELLEN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11830 BRANDON OAKS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-5816
Mailing Address - Country:US
Mailing Address - Phone:210-678-0593
Mailing Address - Fax:210-292-6158
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:ATTN: CREDENTIALS (CMS)
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-292-6115
Practice Address - Fax:210-292-6158
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX566098363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health