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: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 GRANDE BLVD SE STE B
RIO RANCHO NM
87124-1695
US

IV. Provider business mailing address

2582 CAMINO PLATA LOOP NE
RIO RANCHO NM
87144-5825
US

V. Phone/Fax

Practice location:
  • Phone: 505-218-6383
  • Fax: 505-636-6338
Mailing address:
  • Phone: 505-414-0055
  • Fax: 505-636-6338

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: