Healthcare Provider Details

I. General information

NPI: 1285058545
Provider Name (Legal Business Name): NICHOLAS IUNG KENNEDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S 11TH AVE
YAKIMA WA
98902-3242
US

IV. Provider business mailing address

PO BOX 5299 MS: 820-5-PCO
TACOMA WA
98415-0299
US

V. Phone/Fax

Practice location:
  • Phone: 509-454-8888
  • Fax: 509-453-0061
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number64238
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD61373829
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: