MEDICARE: JAN MARIE KENNEDY CRNP

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	363LF0000X	Family Nurse Practitioner	1076407	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1-076407	OTHER	AL	ALABAMA LICENSE
2	51533376	OTHER	AL	BCBS

General Provider Information

NPI Number	:	1730139098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAN MARIE KENNEDY CRNP

Provider Business Mailing Address
First Line	:	PO BOX 5689
Second Line	:	1813 BELTLINE RD SW
City	:	DECATUR
State	:	AL
Zip	:	35601-0689
Country	:	US
Telephone Number	:	256-353-6874
Fax Number	:	256-260-0594

Provider Business Practice Location Address
First Line	:	1813 BELTLINE RD SW
Second Line	:
City	:	DECATUR
State	:	AL
Zip	:	35601-5506
Country	:	US
Telephone Number	:	256-353-6874
Fax Number	:	256-260-0594

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

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	08/17/2010

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