Provider Demographics
NPI:1619234879
Name:KENNEDY, ANN ALICIA (NP-C)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:ALICIA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12815 RALSTON CIR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2447
Mailing Address - Country:US
Mailing Address - Phone:858-837-2335
Mailing Address - Fax:
Practice Address - Street 1:2510 EL CAMINO REAL
Practice Address - Street 2:MINUTE CLINIC
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA272057363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily