Provider Demographics
NPI:1851586358
Name:KENNEDY, AVERY IMARA (APRN, BC)
Entity Type:Individual
Prefix:
First Name:AVERY IMARA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2582 CAMINO PLATA LOOP NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-5825
Mailing Address - Country:US
Mailing Address - Phone:505-414-0055
Mailing Address - Fax:505-636-6338
Practice Address - Street 1:2200 GRANDE BLVD SE STE B
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1695
Practice Address - Country:US
Practice Address - Phone:505-218-6383
Practice Address - Fax:505-636-6338
Is Sole Proprietor?:No
Enumeration Date:2007-09-09
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM68503363LP0808X
WAAP60185590363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health