Healthcare Provider Details

I. General information

NPI: 1063528107
Provider Name (Legal Business Name): ELIZABETH JANE KENNEDY PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 08/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 HARRODSBURG RD SUITE C-305
LEXINGTON KY
40504-3751
US

IV. Provider business mailing address

PO BOX 936
LONDON KY
40743-0936
US

V. Phone/Fax

Practice location:
  • Phone: 859-278-8400
  • Fax: 859-276-3700
Mailing address:
  • Phone: 606-330-7818
  • Fax: 606-330-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA311
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: