Provider Demographics
NPI:1689651358
Name:KENNEDY, WREN T (RN/NP)
Entity Type:Individual
Prefix:MRS
First Name:WREN
Middle Name:T
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RN/NP
Other - Prefix:MRS
Other - First Name:FRANCES
Other - Middle Name:WREN
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN/NP
Mailing Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:MSC10 5590
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-1745
Mailing Address - Fax:505-272-4545
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:MSC10 5590
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-1745
Practice Address - Fax:505-272-8699
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN59810363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3349537Medicaid