MEDICARE: JOANNA RUTH KENNEDY

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	73008658900	UT

General Provider Information

NPI Number	:	1871031708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOANNA RUTH KENNEDY

Provider Business Mailing Address
First Line	:	602 E FORT UNION BLVD
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-2216
Country	:	US
Telephone Number	:	801-313-1010
Fax Number	:

Provider Business Practice Location Address
First Line	:	602 E FORT UNION BLVD
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-2216
Country	:	US
Telephone Number	:	801-313-1010
Fax Number	:

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

Provider Enumeration Date	:	02/12/2017
Last Update Date	:	02/12/2017

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Directions to “ JOANNA RUTH KENNEDY ” Practice Location

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