Provider Demographics
NPI:1619993714
Name:KENNEDY, HOLLY POWELL (CNM)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:POWELL
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:CNM
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 7464
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94120-7464
Mailing Address - Country:US
Mailing Address - Phone:415-206-3103
Mailing Address - Fax:415-206-3872
Practice Address - Street 1:1001 POTRERO AVE
Practice Address - Street 2:RM 6D14
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-206-5679
Practice Address - Fax:415-206-3112
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN582816363LX0001X
CANMW1522367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Not Answered367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANMW015220Medicaid
S69343Medicare UPIN
CANMW015220Medicaid