Provider Demographics
NPI:1629745534
Name:CASSIDY, KENNEDY MARIE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:KENNEDY
Middle Name:MARIE
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KENNEDY
Other - Middle Name:MARIE
Other - Last Name:KRAKAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1016 KELLY CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-5702
Mailing Address - Country:US
Mailing Address - Phone:407-761-5561
Mailing Address - Fax:
Practice Address - Street 1:1016 KELLY CREEK CIR
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-5702
Practice Address - Country:US
Practice Address - Phone:407-761-5561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11014372363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily