Provider Demographics
NPI:1194119016
Name:KENNEDY, CAROL LYNN (APRN)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:LYNN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 W UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2997
Mailing Address - Country:US
Mailing Address - Phone:580-740-4053
Mailing Address - Fax:877-725-8976
Practice Address - Street 1:2701 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2997
Practice Address - Country:US
Practice Address - Phone:580-740-4053
Practice Address - Fax:877-725-8976
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-28
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0074318163W00000X
OK74318363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty