Provider Demographics
NPI:1740864446
Name:KENNEDY, AMANDA JILL
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JILL
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50024 ROBINSON WEST CIR
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-8624
Mailing Address - Country:US
Mailing Address - Phone:662-790-3700
Mailing Address - Fax:662-257-0267
Practice Address - Street 1:50024 ROBINSON WEST CIR
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-8624
Practice Address - Country:US
Practice Address - Phone:662-790-3700
Practice Address - Fax:662-257-0267
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-08
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904484261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care