Provider Demographics
NPI:1922530807
Name:KENNEDY, CHRISTOPHER RYAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:RYAN
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 TURTLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-8373
Mailing Address - Country:US
Mailing Address - Phone:903-276-8324
Mailing Address - Fax:
Practice Address - Street 1:3215 N NORTHHILLS BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4424
Practice Address - Country:US
Practice Address - Phone:479-263-8669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC003186367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered