Provider Demographics
NPI:1730649831
Name:KENNEDY, KAREN ANNE
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:ANNE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10015 NE 339TH ST
Mailing Address - Street 2:
Mailing Address - City:LA CENTER
Mailing Address - State:WA
Mailing Address - Zip Code:98629-2853
Mailing Address - Country:US
Mailing Address - Phone:360-728-9099
Mailing Address - Fax:
Practice Address - Street 1:10015 NE 339TH ST
Practice Address - Street 2:
Practice Address - City:LA CENTER
Practice Address - State:WA
Practice Address - Zip Code:98629-2853
Practice Address - Country:US
Practice Address - Phone:360-728-9099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-23
Last Update Date:2019-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU00001800133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist