Healthcare Provider Details

I. General information

NPI: 1699945576
Provider Name (Legal Business Name): LYNNETTE D HANSEN KENNISON PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6817 SOUTHPOINT PKWY STE 304
JACKSONVILLE FL
32216-6287
US

IV. Provider business mailing address

12484 MASTERS RIDGE DR
JACKSONVILLE FL
32225-5758
US

V. Phone/Fax

Practice location:
  • Phone: 904-296-3113
  • Fax: 904-296-3144
Mailing address:
  • Phone: 904-982-7060
  • Fax: 904-269-3144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP1117892
License Number StateFL

VIII. Authorized Official

Name: LYNETTE HANSEN KENNISON
Title or Position: OWNER
Credential: PH D ARPN
Phone: 904-296-3113