Provider Demographics
NPI:1609818103
Name:KENNEDY, AUDRA LEIGH (CRNA)
Entity Type:Individual
Prefix:MS
First Name:AUDRA
Middle Name:LEIGH
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:AUDRA
Other - Middle Name:LEIGH
Other - Last Name:HEADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:182 PROMONTORY DR W
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7311
Mailing Address - Country:US
Mailing Address - Phone:714-421-1132
Mailing Address - Fax:
Practice Address - Street 1:9400 ROSECRANS AVE
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-2246
Practice Address - Country:US
Practice Address - Phone:562-461-4111
Practice Address - Fax:562-461-4111
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3480367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered