Provider Demographics
NPI:1700122082
Name:KENNEDY, KAREN (PTA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13846 S PARK DR
Mailing Address - Street 2:
Mailing Address - City:MAGALIA
Mailing Address - State:CA
Mailing Address - Zip Code:95954-9598
Mailing Address - Country:US
Mailing Address - Phone:530-873-4085
Mailing Address - Fax:
Practice Address - Street 1:8777 SKYWAY
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-2110
Practice Address - Country:US
Practice Address - Phone:530-872-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT878225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant