Provider Demographics
NPI:1518147776
Name:KENNEMORE, AMY A (RN, APN-BC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:A
Last Name:KENNEMORE
Suffix:
Gender:F
Credentials:RN, APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 LEONA DR
Mailing Address - Street 2:
Mailing Address - City:ASHDOWN
Mailing Address - State:AR
Mailing Address - Zip Code:71822-3105
Mailing Address - Country:US
Mailing Address - Phone:903-826-5020
Mailing Address - Fax:903-764-6546
Practice Address - Street 1:1002 TEXAS BLVD STE 325
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-5118
Practice Address - Country:US
Practice Address - Phone:903-794-6544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR63145363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care