Basic Information
| Provider Information | |||||||||
| NPI: | 1639507288 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNELLEY | ||||||||
| FirstName: | TRACY | ||||||||
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| Credential: | P.A-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13388 | ||||||||
| Address2: | |||||||||
| City: | PALM DESERT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922553388 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 61250 SE COOMBS PL | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977023704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417065930 | ||||||||
| FaxNumber: | 5417065931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2013 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA167858 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 51221 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.