Healthcare Provider Details

I. General information

NPI: 1023944964
Provider Name (Legal Business Name): JOHN CARRICK KENNEDY CHW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16974 S RUSTLING LEAF TRL
VAIL AZ
85641-8748
US

IV. Provider business mailing address

16974 S RUSTLING LEAF TRL
VAIL AZ
85641-8748
US

V. Phone/Fax

Practice location:
  • Phone: 520-703-0064
  • Fax:
Mailing address:
  • Phone: 520-703-0064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: