Healthcare Provider Details

I. General information

NPI: 1801095799
Provider Name (Legal Business Name): RACHEL SHANAN KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 MILITARY W STE 101
BENICIA CA
94510-2446
US

IV. Provider business mailing address

1440 MILITARY W STE 101
BENICIA CA
94510-2446
US

V. Phone/Fax

Practice location:
  • Phone: 707-745-0711
  • Fax:
Mailing address:
  • Phone: 707-745-0711
  • Fax: 707-745-0788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4090
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number53773
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: