Provider Demographics
NPI:1245424761
Name:KENNEDY, TARA (FNP- BC)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:FNP- BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14230 HUNTERS RD
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7335
Mailing Address - Country:US
Mailing Address - Phone:704-316-6611
Mailing Address - Fax:704-316-6612
Practice Address - Street 1:14230 HUNTERS RD
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7335
Practice Address - Country:US
Practice Address - Phone:704-316-6611
Practice Address - Fax:704-316-6612
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5014370363LF0000X, 363LF0000X
CO122656363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO81901879Medicaid
CO81901879Medicaid