Healthcare Provider Details

I. General information

NPI: 1851586358
Provider Name (Legal Business Name): AVERY IMARA KENNEDY APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2007
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 BROADWAY BLVD NE STE 500
ALBUQUERQUE NM
87102-2367
US

IV. Provider business mailing address

PO BOX 1637
OWENSBORO KY
42302-1637
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-0701
  • Fax: 505-232-9055
Mailing address:
  • Phone: 270-689-6577
  • Fax: 270-689-6677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number68503
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: