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NPI Code Detail

MEDICARE: MS. MARY M KENNEDY R.N., N.P., C.N.M.

MEDICARE: MS. MARY M KENNEDY R.N., N.P., C.N.M.
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
1363LW0102XWomen's Health Nurse Practitioner177602CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1177602OTHERCARN LICENSE NUMBER

General Provider Information

NPI Number : 1083608780
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. MARY M KENNEDY R.N., N.P., C.N.M.
Provider Business Mailing Address
First Line : 7601 STONERIDGE DR
Second Line : THE PERMANENTE MEDICAL GROUP
City : PLEASANTON
State : CA
Zip : 94588-4501
Country : US
Telephone Number : 925-847-5629
Fax Number : 925-847-5148
Provider Business Practice Location Address
First Line : 7601 STONERIDGE DR
Second Line : THE PERMANENTE MEDICAL GROUP
City : PLEASANTON
State : CA
Zip : 94588-4501
Country : US
Telephone Number : 925-847-5629
Fax Number : 925-847-5148
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/08/2005
Last Update Date : 07/08/2007

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