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NPI Code Detail

MEDICARE: KENNEDY GUEST

MEDICARE: KENNEDY GUEST
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
1106S00000XBehavior TechnicianOK

General Provider Information

NPI Number : 1790637841
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENNEDY GUEST
Provider Business Mailing Address
First Line : 11412 N 134TH EAST AVE STE C3
Second Line :
City : OWASSO
State : OK
Zip : 74055-4969
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 11412 N 134TH EAST AVE STE C3
Second Line :
City : OWASSO
State : OK
Zip : 74055-4969
Country : US
Telephone Number : 918-376-3087
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/11/2026
Last Update Date : 02/11/2026

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Directions to “ KENNEDY GUEST ” Practice Location

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