Healthcare Provider Details

I. General information

NPI: 1023491743
Provider Name (Legal Business Name): MICHAEL KENNEDY PHD, ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MICHAEL GLENN KENNEDY PHD, ARNP

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 SUMMIT AVE THERAPEUTIC HEALTH SERVICES
SEATTLE WA
98101-2831
US

IV. Provider business mailing address

PO BOX 1275 251 EAST NORTHCREST DRIVE
ALLYN WA
98524-1275
US

V. Phone/Fax

Practice location:
  • Phone: 206-323-0930
  • Fax:
Mailing address:
  • Phone: 360-990-6796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN00087927
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberAP30002443
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: