=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700122082
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN KENNEDY PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2012
-----------------------------------------------------
Last Update Date | 12/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8777 SKYWAY
-----------------------------------------------------
City | PARADISE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95969-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-872-3200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13846 S PARK DR
-----------------------------------------------------
City | MAGALIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95954-9598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-873-4085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | AT878
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------