Provider Demographics
NPI:1801095799
Name:KENNEDY, RACHEL SHANAN
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:SHANAN
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 1:1440 MILITARY W
Mailing Address - Street 2:STE 101
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2446
Mailing Address - Country:US
Mailing Address - Phone:707-745-0711
Mailing Address - Fax:707-745-0788
Practice Address - Street 1:1440 MILITARY W STE 101
Practice Address - Street 2:
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-2446
Practice Address - Country:US
Practice Address - Phone:707-745-0711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4090363AM0700X
CA53773363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical