Provider Demographics
NPI:1275059461
Name:KENNEDY, EVALYN S
Entity Type:Individual
Prefix:
First Name:EVALYN
Middle Name:S
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 1:2230 WOODBURY PIKE STE 2
Mailing Address - Street 2:
Mailing Address - City:LOYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16659-9506
Mailing Address - Country:US
Mailing Address - Phone:814-766-3485
Mailing Address - Fax:814-766-2379
Practice Address - Street 1:2230 WOODBURY PIKE STE 2
Practice Address - Street 2:
Practice Address - City:LOYSBURG
Practice Address - State:PA
Practice Address - Zip Code:16659-9506
Practice Address - Country:US
Practice Address - Phone:814-766-3485
Practice Address - Fax:814-766-2379
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017807363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily