Provider Demographics
NPI:1649026063
Name:SHIELDS, KENNEDY MARIE (CHAP)
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:MARIE
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:CHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7033 E TUDOR RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1262
Mailing Address - Country:US
Mailing Address - Phone:907-729-8901
Mailing Address - Fax:907-729-5180
Practice Address - Street 1:1008 MAIN STRRET
Practice Address - Street 2:
Practice Address - City:KOKHANOK
Practice Address - State:AK
Practice Address - Zip Code:99606-9998
Practice Address - Country:US
Practice Address - Phone:907-282-2203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker