Provider Demographics
NPI:1467801605
Name:KENNEDY, KAYLA NICOLE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KAYLA
Middle Name:NICOLE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 MOHAWK ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1911
Mailing Address - Country:US
Mailing Address - Phone:203-560-7008
Mailing Address - Fax:
Practice Address - Street 1:22 PINE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-6948
Practice Address - Country:US
Practice Address - Phone:860-584-8291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical