Provider Demographics
NPI:1669123741
Name:KENNEDY, KATIE ALYSSA (APRN)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ALYSSA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ALYSSA
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1204 GREYSTONE LN
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-9567
Mailing Address - Country:US
Mailing Address - Phone:850-776-6851
Mailing Address - Fax:
Practice Address - Street 1:8325 UNIVERSITY PKWY STE A
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-4949
Practice Address - Country:US
Practice Address - Phone:850-324-9633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61429532363L00000X
FLAPRN11017401363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner