Healthcare Provider Details

I. General information

NPI: 1336779305
Provider Name (Legal Business Name): AMANDA MARIE KENNEDY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2020
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2708 S RIFE MEDICAL LN STE 140
ROGERS AR
72758-1455
US

IV. Provider business mailing address

2708 S RIFE MEDICAL LN STE 140
ROGERS AR
72758-1455
US

V. Phone/Fax

Practice location:
  • Phone: 479-338-3720
  • Fax: 479-338-3749
Mailing address:
  • Phone: 479-338-3720
  • Fax: 479-338-3749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2020040255
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number123431
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: