Provider Demographics
NPI:1376710541
Name:KENNICOTT, FELICIA D (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:FELICIA
Middle Name:D
Last Name:KENNICOTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 NW BOCA RATON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-1610
Mailing Address - Country:US
Mailing Address - Phone:561-338-7722
Mailing Address - Fax:561-338-7785
Practice Address - Street 1:1445 NW BOCA RATON BLVD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-1610
Practice Address - Country:US
Practice Address - Phone:561-338-7722
Practice Address - Fax:561-338-7785
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5317363AM0700X
FLPA9115617363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical