Provider Demographics
NPI:1063937696
Name:KENNEDY, AMANDA LAUREN (AGACNP-BC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LAUREN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:PETERSON-BLEDSOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGACNP-BC
Mailing Address - Street 1:4615 NORTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:OH
Mailing Address - Zip Code:45103-1385
Mailing Address - Country:US
Mailing Address - Phone:513-917-9697
Mailing Address - Fax:513-901-8068
Practice Address - Street 1:11690 GROOMS RD
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-1412
Practice Address - Country:US
Practice Address - Phone:513-917-9697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.021254363LA2100X
OHRN.391672163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse