Provider Demographics
NPI:1669947610
Name:KENNEDY, STACY JO (FNP- BC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:JO
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:FNP- BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 DOUGLAS DR
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-3148
Mailing Address - Country:US
Mailing Address - Phone:307-371-1601
Mailing Address - Fax:
Practice Address - Street 1:1453A DEWAR DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5812
Practice Address - Country:US
Practice Address - Phone:307-382-2466
Practice Address - Fax:888-395-0359
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY30260.1816363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily