Provider Demographics
NPI:1467798702
Name:K L KENNEDY LLC
Entity Type:Organization
Organization Name:K L KENNEDY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:L
Authorized Official - Last Name:KENNEDY-EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:520-232-1019
Mailing Address - Street 1:5090 N CORTE DE CATALONIA
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-6078
Mailing Address - Country:US
Mailing Address - Phone:520-232-1019
Mailing Address - Fax:520-299-1680
Practice Address - Street 1:5090 N CORTE DE CATALONIA
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6078
Practice Address - Country:US
Practice Address - Phone:520-232-1019
Practice Address - Fax:520-299-1680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN122326208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
R16661Medicare UPIN