Provider Demographics
NPI:1619737905
Name:CHRISTA, KENNEDY (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:
Last Name:CHRISTA
Suffix:
Gender:F
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 1:6032 MARGIE COLLINS DR
Mailing Address - Street 2:
Mailing Address - City:OWENS CROSS ROADS
Mailing Address - State:AL
Mailing Address - Zip Code:35763-4819
Mailing Address - Country:US
Mailing Address - Phone:870-919-3862
Mailing Address - Fax:
Practice Address - Street 1:927 FRANKLIN ST SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4306
Practice Address - Country:US
Practice Address - Phone:256-539-2728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2364363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant