Provider Demographics
NPI:1760491435
Name:KENNEDY, PHYLLIS CECILIA (ARNP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:CECILIA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1897 PALM BEACH LAKES BLVD
Mailing Address - Street 2:SUITE 222
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-3507
Mailing Address - Country:US
Mailing Address - Phone:561-719-2385
Mailing Address - Fax:561-659-2825
Practice Address - Street 1:1897 PALM BEACH LAKES BLVD
Practice Address - Street 2:SUITE 222
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-3507
Practice Address - Country:US
Practice Address - Phone:561-719-2385
Practice Address - Fax:561-659-2825
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2594912363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL311158000Medicaid
FLK2512Medicare ID - Type UnspecifiedPRACTICE PROVIDER PWK,IN
FL311158000Medicaid