Basic Information
| Provider Information | |||||||||
| NPI: | 1003299074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | MAMIE | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 BELLEVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | BREWTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 364261500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2518093208 | ||||||||
| FaxNumber: | 2518675999 | ||||||||
| Practice Location | |||||||||
| Address1: | 1121 BELLEVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | BREWTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 364261500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2518093208 | ||||||||
| FaxNumber: | 2518675999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2015 | ||||||||
| LastUpdateDate: | 07/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1-116711 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.