Provider Demographics
NPI:1669544383
Name:KENNEDY, BETH A (NP)
Entity type:Individual
Prefix:MS
First Name:BETH
Middle Name:A
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 N SWITZER CANYON DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4824
Mailing Address - Country:US
Mailing Address - Phone:928-779-5707
Mailing Address - Fax:928-779-5753
Practice Address - Street 1:930 N SWITZER CANYON DR
Practice Address - Street 2:SUITE 202
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4824
Practice Address - Country:US
Practice Address - Phone:928-779-5707
Practice Address - Fax:928-779-5753
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1689363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP1689OtherNP LICENSE #
AZRN121857OtherRN LICENSE #
AZ202101Medicaid