Healthcare Provider Details

I. General information

NPI: 1871128090
Provider Name (Legal Business Name): SHANNON EILEEN KENNEDY DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16515 S 40TH ST STE 133
PHOENIX AZ
85048-0560
US

IV. Provider business mailing address

16515 S 40TH ST STE 133
PHOENIX AZ
85048-0560
US

V. Phone/Fax

Practice location:
  • Phone: 480-704-6133
  • Fax: 480-704-5874
Mailing address:
  • Phone: 480-704-6133
  • Fax: 480-704-5874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8957
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: