Provider Demographics
NPI:1730646431
Name:KENNICUTT, LAURA JOANNA (FNP-C)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:JOANNA
Last Name:KENNICUTT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6565 E CARONDELET DR STE 275
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3529
Mailing Address - Country:US
Mailing Address - Phone:520-298-0147
Mailing Address - Fax:
Practice Address - Street 1:6565 E CARONDELET DR STE 275
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3529
Practice Address - Country:US
Practice Address - Phone:520-298-0147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRNP223092363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MK5179103OtherDEA REGISTRATION NUMBER