MEDICARE: DR. AMANDA DAWN KENNEDY DNP, PMHNP

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	163W00000X	Registered Nurse	946888	TX
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1095930	TX

General Provider Information

NPI Number	:	1396460010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMANDA DAWN KENNEDY DNP, PMHNP

Provider Business Mailing Address
First Line	:	4364 WESTERN CENTER BLVD # 2221
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-2043
Country	:	US
Telephone Number	:	817-393-2061
Fax Number	:	817-393-2590

Provider Business Practice Location Address
First Line	:	4364 WESTERN CENTER BLVD # 2221
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-2043
Country	:	US
Telephone Number	:	817-393-2061
Fax Number	:	817-393-2590

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

Provider Enumeration Date	:	10/05/2022
Last Update Date	:	10/05/2022

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