Healthcare Provider Details

I. General information

NPI: 1104790724
Provider Name (Legal Business Name): KENNEDY S WILKES APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 BRAZELTON ST UNIT 6
SAVANNAH TN
38372-3080
US

IV. Provider business mailing address

PO BOX 58
SAVANNAH TN
38372-0058
US

V. Phone/Fax

Practice location:
  • Phone: 731-438-3090
  • Fax: 731-256-0757
Mailing address:
  • Phone: 731-438-3090
  • Fax: 731-256-0757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number39985
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: