Provider Demographics
NPI:1013971258
Name:KENNELLY, KATHRYN IRENE (NP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:IRENE
Last Name:KENNELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:IRENE
Other - Last Name:CAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:617 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-5726
Mailing Address - Country:US
Mailing Address - Phone:972-423-8110
Mailing Address - Fax:972-423-1699
Practice Address - Street 1:617 E 16TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-5726
Practice Address - Country:US
Practice Address - Phone:972-423-8110
Practice Address - Fax:972-423-1699
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0804014363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169741902Medicaid
TX169741902Medicaid
TX8D7027Medicare PIN