Provider Demographics
NPI:1386181048
Name:KENNY, CASSANDRA LAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:LAYNE
Last Name:KENNY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:LAYNE
Other - Last Name:PETRILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:2001 ROCKVIEW DR
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-5711
Practice Address - Country:US
Practice Address - Phone:682-529-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11056363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant