Provider Demographics
NPI:1558530568
Name:KENNEY, SHAWN EDWARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:EDWARD
Last Name:KENNEY
Suffix:
Gender:M
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 1:2ND MEDICAL BATTALION CAMP LEJEUNE
Mailing Address - Street 2:PSC BOX 20129
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0129
Mailing Address - Country:US
Mailing Address - Phone:910-451-0695
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2575
Practice Address - Country:US
Practice Address - Phone:910-451-0695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-23
Last Update Date:2017-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07462363A00000X
1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman