Provider Demographics
NPI:1912179227
Name:KENNEDY, CHRISTIE ELAINE (DNP)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIE
Middle Name:ELAINE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:CHRISTIE
Other - Middle Name:ELAINE
Other - Last Name:TISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:6098 COPPER DR
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-6002
Mailing Address - Country:US
Mailing Address - Phone:904-397-0923
Mailing Address - Fax:
Practice Address - Street 1:368 NE FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055
Practice Address - Country:US
Practice Address - Phone:386-292-8001
Practice Address - Fax:386-292-8002
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9171598363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL309119800Medicaid
FL309119800Medicaid