Provider Demographics
NPI:1396772505
Name:KENNEDY, VICKY T (NP-C)
Entity type:Individual
Prefix:
First Name:VICKY
Middle Name:T
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0623
Mailing Address - Country:US
Mailing Address - Phone:434-584-5502
Mailing Address - Fax:434-584-5509
Practice Address - Street 1:1755 N MECKLENBURG AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-4080
Practice Address - Country:US
Practice Address - Phone:434-584-5502
Practice Address - Fax:434-584-5509
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166150363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP47150Medicare UPIN
VA006718J90Medicare ID - Type Unspecified