Provider Demographics
NPI:1639507288
Name:KENNELLEY, TRACY (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:KENNELLEY
Suffix:
Gender:F
Credentials:PA-C
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 6095
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-6095
Mailing Address - Country:US
Mailing Address - Phone:541-706-5922
Mailing Address - Fax:541-706-6869
Practice Address - Street 1:2200 NE NEFF RD STE 302
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4279
Practice Address - Country:US
Practice Address - Phone:541-706-6915
Practice Address - Fax:541-706-6733
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51221363A00000X
ORPA167858363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant