Provider Demographics
NPI:1699945576
Name:LYNNETTE D HANSEN KENNISON PA
Entity type:Organization
Organization Name:LYNNETTE D HANSEN KENNISON PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:HANSEN
Authorized Official - Last Name:KENNISON
Authorized Official - Suffix:
Authorized Official - Credentials:PH D ARPN
Authorized Official - Phone:904-296-3113
Mailing Address - Street 1:12484 MASTERS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-5758
Mailing Address - Country:US
Mailing Address - Phone:904-982-7060
Mailing Address - Fax:904-269-3144
Practice Address - Street 1:6817 SOUTHPOINT PKWY STE 304
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6287
Practice Address - Country:US
Practice Address - Phone:904-296-3113
Practice Address - Fax:904-296-3144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1117892363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty