Provider Demographics
NPI:1760417489
Name:KENNEDY, PATRICIA K (NP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:K
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NP
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 3160
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85217-3160
Mailing Address - Country:US
Mailing Address - Phone:480-288-5328
Mailing Address - Fax:480-288-5339
Practice Address - Street 1:150 N OCOTILLO DR
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85220-3740
Practice Address - Country:US
Practice Address - Phone:480-983-0571
Practice Address - Fax:480-983-0896
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN055120363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ470021Medicaid
AZ73677Medicare ID - Type Unspecified