Provider Demographics
NPI:1578864005
Name:KENNEDY, DEBRA R (RN, LMP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:R
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RN, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1318
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-1318
Mailing Address - Country:US
Mailing Address - Phone:360-629-0110
Mailing Address - Fax:
Practice Address - Street 1:9416 271ST ST NW
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-8094
Practice Address - Country:US
Practice Address - Phone:360-629-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60172187225700000X
WARN00095745163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No163W00000XNursing Service ProvidersRegistered Nurse