Provider Demographics
NPI:1629097365
Name:KENNEDY, MICHELE RENEE (PA)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:RENEE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11515 212TH ST E
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-6484
Mailing Address - Country:US
Mailing Address - Phone:210-213-1576
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CTR
Practice Address - Street 2:9040 REID ST ATTN: MCHJ-QCR
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1100
Practice Address - Country:US
Practice Address - Phone:253-968-2252
Practice Address - Fax:253-968-3278
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant