Basic Information
| Provider Information | |||||||||
| NPI: | 1538420922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | BROOKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEINLY | ||||||||
| OtherFirstName: | RACHEL | ||||||||
| OtherMiddleName: | BROOKE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 14010 SMOKETOWN RD | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221924704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035800181 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3300 GALLOWS ROAD | ||||||||
| Address2: | |||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220424704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037764001 | ||||||||
| FaxNumber: | 7037767113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2012 | ||||||||
| LastUpdateDate: | 10/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0110003902 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.