Provider Demographics
NPI:1467655092
Name:KENNEDY, DIANE ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ELIZABETH
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11180 WARNER AVE
Mailing Address - Street 2:SUITE 455
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7501
Mailing Address - Country:US
Mailing Address - Phone:714-556-0536
Mailing Address - Fax:
Practice Address - Street 1:11180 WARNER AVE
Practice Address - Street 2:SUITE 455
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708
Practice Address - Country:US
Practice Address - Phone:714-556-0536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-10
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP7672363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health