Provider Demographics
NPI:1386989788
Name:KENNEDY, ADRIENNE (PA)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ADRIENNE
Other - Middle Name:
Other - Last Name:KISCHNICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1100 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-1312
Mailing Address - Country:US
Mailing Address - Phone:989-348-5461
Mailing Address - Fax:
Practice Address - Street 1:1100 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-1312
Practice Address - Country:US
Practice Address - Phone:989-348-5461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant