Healthcare Provider Details

I. General information

NPI: 1083949986
Provider Name (Legal Business Name): KERRY MARIE KENNEDY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2009
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7066 STILLWATER BLVD N
OAKDALE MN
55128-3937
US

IV. Provider business mailing address

7066 STILLWATER BLVD N
OAKDALE MN
55128-3937
US

V. Phone/Fax

Practice location:
  • Phone: 612-227-3075
  • Fax: 651-251-5128
Mailing address:
  • Phone: 651-251-5044
  • Fax: 651-251-5128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberR123669
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0908
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: