=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447507348
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDRIA KAY KENNEDY PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2012
-----------------------------------------------------
Last Update Date | 08/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 W 4TH ST
-----------------------------------------------------
City | MCPHERSON
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67460-2300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-241-4201
-----------------------------------------------------
Fax | 620-241-4210
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 W DOUGLAS AVE STE 1040
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67202-3013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-263-0003
-----------------------------------------------------
Fax | 316-263-1241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 1402381
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------