Healthcare Provider Details

I. General information

NPI: 1275456345
Provider Name (Legal Business Name): PATRICK RYAN KENNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 W WALNUT ST
JOHNSON CITY TN
37604-6527
US

IV. Provider business mailing address

1292 HARMONY RD
JONESBOROUGH TN
37659-3228
US

V. Phone/Fax

Practice location:
  • Phone: 423-439-6315
  • Fax:
Mailing address:
  • Phone: 423-771-1534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number115605381
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: