Provider Demographics
NPI:1255135422
Name:BROOKS, KENNEDY PAIGE
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:PAIGE
Last Name:BROOKS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:KENNEDY
Other - Middle Name:PAIGE
Other - Last Name:DYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:910 BROOKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-8635
Mailing Address - Country:US
Mailing Address - Phone:480-794-0063
Mailing Address - Fax:
Practice Address - Street 1:1540 PURDUE DR STE 101
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5510
Practice Address - Country:US
Practice Address - Phone:910-491-2437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-15269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant