Provider Demographics
NPI:1861536989
Name:KENNEDY, BRENA SUZANN (NP)
Entity type:Individual
Prefix:MS
First Name:BRENA
Middle Name:SUZANN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9354 A. S. SIX SHOOTER CYN RD.
Mailing Address - Street 2:
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501
Mailing Address - Country:US
Mailing Address - Phone:928-425-2804
Mailing Address - Fax:928-425-8406
Practice Address - Street 1:1100 N BROAD ST
Practice Address - Street 2:SUITE B
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-2757
Practice Address - Country:US
Practice Address - Phone:928-425-8200
Practice Address - Fax:928-425-8406
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2147363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily