Provider Demographics
NPI:1437120144
Name:KENNEDY, JULIE ALLEN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ALLEN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MISS
Other - First Name:JULIE
Other - Middle Name:CAROL
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 80217
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85060-0217
Mailing Address - Country:US
Mailing Address - Phone:602-385-2115
Mailing Address - Fax:480-418-3323
Practice Address - Street 1:2940 E BANNER GATEWAY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2168
Practice Address - Country:US
Practice Address - Phone:480-964-2908
Practice Address - Fax:480-833-2136
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2765363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3Z3970OtherHEALTHNET
AZ774811Medicaid
AZZ75795Medicare PIN
AZP00845776Medicare PIN
AZP83531Medicare UPIN