MEDICARE: MS. SALLY JEAN KENNEDY NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	RN-39547	AZ
2	363LF0000X	Family Nurse Practitioner	RN-39547	AZ

General Provider Information

NPI Number	:	1043293103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SALLY JEAN KENNEDY NP

Provider Business Mailing Address
First Line	:	2322 S. ROGERS
Second Line	:	#54
City	:	MESA
State	:	AZ
Zip	:	85202-6561
Country	:	US
Telephone Number	:	480-820-7957
Fax Number	:

Provider Business Practice Location Address
First Line	:	1898 E SOUTHERN AVE
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85282-5836
Country	:	US
Telephone Number	:	480-838-0068
Fax Number	:	480-838-3409

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	09/11/2025

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