Provider Demographics
NPI:1093821894
Name:KENNEDY, MARY KATHRYN (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 RODDEN DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3620
Mailing Address - Country:US
Mailing Address - Phone:940-627-7772
Mailing Address - Fax:
Practice Address - Street 1:1845 S FM 51 UNIT A-2
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3764
Practice Address - Country:US
Practice Address - Phone:940-727-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX234256367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88938803Medicaid
TX88938803Medicaid