Provider Demographics
NPI:1295565471
Name:KENNEALLY, ALICE RAVEN (PA-C)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:RAVEN
Last Name:KENNEALLY
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E DAHLIA AVE
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6463
Mailing Address - Country:US
Mailing Address - Phone:907-376-2411
Mailing Address - Fax:907-352-3301
Practice Address - Street 1:425 E DAHLIA AVE
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6463
Practice Address - Country:US
Practice Address - Phone:907-376-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-03
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AK233490363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program