Provider Demographics
NPI:1245424761
Name:KENNEDY, TARA (FNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10826 MALLARD CREEK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-7785
Mailing Address - Country:US
Mailing Address - Phone:704-774-3044
Mailing Address - Fax:704-774-3045
Practice Address - Street 1:10826 MALLARD CREEK RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-7785
Practice Address - Country:US
Practice Address - Phone:704-774-3044
Practice Address - Fax:704-774-3045
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5334363LA2200X
CO122656363LF0000X
NC5014370363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO81901879Medicaid
CO81901879Medicaid