Provider Demographics
NPI:1699189845
Name:KENNEDY, MARK (ATC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7703 W SHADOW LAKES ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1913
Mailing Address - Country:US
Mailing Address - Phone:316-425-0692
Mailing Address - Fax:
Practice Address - Street 1:707 N EMPORIA ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3707
Practice Address - Country:US
Practice Address - Phone:316-858-3524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-00513246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other