Healthcare Provider Details

I. General information

NPI: 1649575820
Provider Name (Legal Business Name): JOSHUA M KENNEDY ST,XT,HCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21911 76TH AVE W SUITE 106
EDMONDS WA
98026-7918
US

IV. Provider business mailing address

21911 76TH AVE W SUITE 106
EDMONDS WA
98026-7918
US

V. Phone/Fax

Practice location:
  • Phone: 425-778-2220
  • Fax: 425-778-7701
Mailing address:
  • Phone: 425-778-2220
  • Fax: 425-778-7701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberST60168312
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: