Provider Demographics
NPI:1669421046
Name:KENNEDY, KATHLEEN L (PA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:200 SCENERY DR
Practice Address - Street 2:MC 56-02
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7974
Practice Address - Country:US
Practice Address - Phone:814-231-4560
Practice Address - Fax:814-231-6246
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA051200207R00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q60090Medicare UPIN
PA97028Medicare ID - Type Unspecified