Healthcare Provider Details

I. General information

NPI: 1134059058
Provider Name (Legal Business Name): HALEY MAI KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HALEY MAI THAM

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 GARDEN LN
BRISTOL VA
24201-1512
US

IV. Provider business mailing address

549 GARDEN LN
BRISTOL VA
24201-1512
US

V. Phone/Fax

Practice location:
  • Phone: 423-383-1741
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: