Provider Demographics
NPI:1811028673
Name:KENNEDY, MARK S (ARNP-BC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:ARNP-BC
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 4725
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-4725
Mailing Address - Country:US
Mailing Address - Phone:417-451-7425
Mailing Address - Fax:417-451-7455
Practice Address - Street 1:1355 ROCKETDYNE RD
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-3106
Practice Address - Country:US
Practice Address - Phone:417-451-7425
Practice Address - Fax:417-451-7455
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK66851363L00000X
KS45922363L00000X
MO141364363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q78476Medicare UPIN