Provider Demographics
NPI:1659832822
Name:KENNEDY, TANNER MICHAEL
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:MICHAEL
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 STATE AVE. STE. I PMB 93
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270
Mailing Address - Country:US
Mailing Address - Phone:425-598-3600
Mailing Address - Fax:
Practice Address - Street 1:17807 CROOKED MILE RD APT 7
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:WA
Practice Address - Zip Code:98252-8742
Practice Address - Country:US
Practice Address - Phone:425-598-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHM60927797374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide