Provider Demographics
NPI:1477931269
Name:KENNEDY, JANILE SUSAN (LICENSED NURSE)
Entity Type:Individual
Prefix:
First Name:JANILE
Middle Name:SUSAN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LICENSED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 YELLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5234
Mailing Address - Country:US
Mailing Address - Phone:307-789-2652
Mailing Address - Fax:307-789-6227
Practice Address - Street 1:108 YELLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5234
Practice Address - Country:US
Practice Address - Phone:307-789-2652
Practice Address - Fax:307-789-6227
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4838164W00000X
WY190032638 A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No164W00000XNursing Service ProvidersLicensed Practical Nurse