Healthcare Provider Details

I. General information

NPI: 1568979474
Provider Name (Legal Business Name): RUTH ANN KENNEDY PCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RUTH ANN BAILENGEE

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 01/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 BUNA VISTA DRIVE
ELKVIEW WV
25071
US

IV. Provider business mailing address

145 BUNA VISTA DRIVE
ELKVIEW WV
25071
US

V. Phone/Fax

Practice location:
  • Phone: 304-965-7756
  • Fax:
Mailing address:
  • Phone: 304-345-5462
  • Fax: 304-558-4563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: