=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770410805
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WIKEMA I KENNEDY RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2026
-----------------------------------------------------
Last Update Date | 05/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 812 GREENWOOD AVE
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37040-4068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-920-7355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 198 BOB WHITE DR
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37042-7301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-572-2300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 281954
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------