Provider Demographics
NPI:1801345574
Name:KENNEDY, TANYA F (FNP)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:F
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 957683
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-7683
Mailing Address - Country:US
Mailing Address - Phone:573-366-6149
Mailing Address - Fax:573-756-6807
Practice Address - Street 1:1106 HAZEL LN
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1999
Practice Address - Country:US
Practice Address - Phone:573-756-6751
Practice Address - Fax:573-756-6807
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016032673363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2016032673OtherSTATE FNP LICENSE