Provider Demographics
NPI:1700474541
Name:KENNEDY, SHANNON RENE' (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENE'
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1105
Mailing Address - Country:US
Mailing Address - Phone:806-725-5411
Mailing Address - Fax:806-723-7766
Practice Address - Street 1:400 ROSALIND REDFERN GROVER PKWY
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5846
Practice Address - Country:US
Practice Address - Phone:432-221-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX722924163W00000X
TX1014885208M00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist