Provider Demographics
NPI:1639479124
Name:KENNEDY, AMY ANN (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ANN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 VERMONT ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-4380
Mailing Address - Country:US
Mailing Address - Phone:360-676-1656
Mailing Address - Fax:
Practice Address - Street 1:2905 CONNELLY AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-8225
Practice Address - Country:US
Practice Address - Phone:360-734-4181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-30
Last Update Date:2010-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160068307225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant