Provider Demographics
NPI:1841922895
Name:BOEHM, KENNEDIE ANN (DNP, FNP)
Entity type:Individual
Prefix:
First Name:KENNEDIE
Middle Name:ANN
Last Name:BOEHM
Suffix:
Gender:F
Credentials:DNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5308 W LEGENDA CT
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-5408
Mailing Address - Country:US
Mailing Address - Phone:701-214-1574
Mailing Address - Fax:
Practice Address - Street 1:19005 SE 34TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-1450
Practice Address - Country:US
Practice Address - Phone:360-726-6720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61329027363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily