Provider Demographics
NPI:1568979474
Name:KENNEDY, RUTH ANN (PCA)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:ANN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:ANN
Other - Last Name:BAILENGEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:145 BUNA VISTA DRIVE
Mailing Address - Street 2:
Mailing Address - City:ELKVIEW
Mailing Address - State:WV
Mailing Address - Zip Code:25071
Mailing Address - Country:US
Mailing Address - Phone:304-345-5462
Mailing Address - Fax:304-558-4563
Practice Address - Street 1:145 BUNA VISTA DRIVE
Practice Address - Street 2:
Practice Address - City:ELKVIEW
Practice Address - State:WV
Practice Address - Zip Code:25071
Practice Address - Country:US
Practice Address - Phone:304-965-7756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810014491OtherPROVIDER ID