Provider Demographics
NPI:1962763912
Name:KENNEDY, HEATHER (RN, CRNP, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RN, CRNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 S CHERRY GROVE AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-4250
Mailing Address - Country:US
Mailing Address - Phone:240-603-9998
Mailing Address - Fax:
Practice Address - Street 1:4508 FOUR SEASONS PL
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-4000
Practice Address - Country:US
Practice Address - Phone:240-305-3195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2022009733363LP0808X
MDR190030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse