Provider Demographics
NPI:1962763912
Name:KENNEDY, HEATHER (PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 INDUSTRIAL PARK DRIVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602
Mailing Address - Country:US
Mailing Address - Phone:240-822-2683
Mailing Address - Fax:443-782-3495
Practice Address - Street 1:2 INDUSTRIAL PARK DRIVE
Practice Address - Street 2:SUITE E
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602
Practice Address - Country:US
Practice Address - Phone:240-822-2683
Practice Address - Fax:443-782-3495
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2022009733363LP0808X
MDR190030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse