Provider Demographics
NPI:1447596804
Name:KENNEDY, HEATHER C (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:C
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:C
Other - Last Name:LYLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7900 NW 23RD ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-4961
Mailing Address - Country:US
Mailing Address - Phone:405-470-3232
Mailing Address - Fax:405-470-3233
Practice Address - Street 1:7900 NW 23RD ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-4961
Practice Address - Country:US
Practice Address - Phone:405-470-3232
Practice Address - Fax:405-470-3233
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2191363AM0700X
OK2191363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200506010AMedicaid