Healthcare Provider Details

I. General information

NPI: 1588156483
Provider Name (Legal Business Name): STEPHANIE JEAN KENNEDY-SOUTHALL FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E BROOKLYN ST
LINDEN TN
37096-3515
US

IV. Provider business mailing address

PO BOX 916
LINDEN TN
37096-0916
US

V. Phone/Fax

Practice location:
  • Phone: 931-589-2104
  • Fax: 931-589-2513
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number188184
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN24410
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: