Healthcare Provider Details

I. General information

NPI: 1124001516
Provider Name (Legal Business Name): RENE' D. KENNEY RN, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 TANAGA AVE
KENAI AK
99611-7910
US

IV. Provider business mailing address

1611 TANAGA AVE
KENAI AK
99611-7910
US

V. Phone/Fax

Practice location:
  • Phone: 907-395-0526
  • Fax:
Mailing address:
  • Phone: 907-395-0526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number824
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: