Provider Demographics
NPI:1629061627
Name:KENNEDY, PAMELA (CRNA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4549 RAYNOR COURT
Mailing Address - Street 2:OUTPATIENT ANESTHESIA SPECIALISTS
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040
Mailing Address - Country:US
Mailing Address - Phone:513-204-5696
Mailing Address - Fax:877-284-4283
Practice Address - Street 1:2000 JOSEPH E. SANKER BOULEVARD
Practice Address - Street 2:THE UROLOGY CENTER
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212
Practice Address - Country:US
Practice Address - Phone:513-841-7600
Practice Address - Fax:513-841-7601
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH126547367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0756472Medicaid
OH0756472Medicaid