Provider Demographics
NPI:1104094424
Name:KENNEDY, MICHELLE M (RNC WHNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RNC WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BAHRT CIR
Mailing Address - Street 2:
Mailing Address - City:SITKA
Mailing Address - State:AK
Mailing Address - Zip Code:99835-7237
Mailing Address - Country:US
Mailing Address - Phone:907-966-8772
Mailing Address - Fax:
Practice Address - Street 1:222 TONGASS DR
Practice Address - Street 2:514 LAKE STREET SUITE B
Practice Address - City:SITKA
Practice Address - State:AK
Practice Address - Zip Code:99835-9416
Practice Address - Country:US
Practice Address - Phone:907-966-8772
Practice Address - Fax:907-966-8708
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK946363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1104094424Medicaid