Provider Demographics
NPI:1326118365
Name:KENNEDY, KAREN J (PA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:J
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5335 LAKESHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-6123
Mailing Address - Country:US
Mailing Address - Phone:707-263-7725
Mailing Address - Fax:707-263-1096
Practice Address - Street 1:5335 LAKESHORE BLVD
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6123
Practice Address - Country:US
Practice Address - Phone:707-263-7725
Practice Address - Fax:707-263-1096
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15788363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical