Provider Demographics
NPI:1366176414
Name:KENNICUTT, JOSIE L
Entity type:Individual
Prefix:
First Name:JOSIE
Middle Name:L
Last Name:KENNICUTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 COBBLER LN
Mailing Address - Street 2:
Mailing Address - City:SUTHERLAND
Mailing Address - State:NE
Mailing Address - Zip Code:69165-7278
Mailing Address - Country:US
Mailing Address - Phone:308-289-3574
Mailing Address - Fax:
Practice Address - Street 1:625 W WILLIAM AVE
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-0026
Practice Address - Country:US
Practice Address - Phone:308-289-3574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant