Provider Demographics
NPI:1952052433
Name:KENNEDY, KATHRYN ELOISE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELOISE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26800 CROWN VALLEY PKWY STE 205
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6384
Mailing Address - Country:US
Mailing Address - Phone:949-364-3330
Mailing Address - Fax:
Practice Address - Street 1:26800 CROWN VALLEY PKWY STE 205
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6384
Practice Address - Country:US
Practice Address - Phone:949-364-3330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-15
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61657363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty