Provider Demographics
NPI:1831321348
Name:KENNEDY, ANDREA MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2036 N COLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7309
Mailing Address - Country:US
Mailing Address - Phone:208-514-4400
Mailing Address - Fax:208-514-4404
Practice Address - Street 1:3041 E COPPER POINT DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1740
Practice Address - Country:US
Practice Address - Phone:208-514-4400
Practice Address - Fax:208-514-4404
Is Sole Proprietor?:No
Enumeration Date:2009-08-17
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3971363LF0000X
IDNP-1265A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDB08329018Medicare UPIN