Basic Information
| Provider Information | |||||||||
| NPI: | 1689651358 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | WREN | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN/NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KENNEDY | ||||||||
| OtherFirstName: | FRANCES | ||||||||
| OtherMiddleName: | WREN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN/.NP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | MSC10 5590 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052721745 | ||||||||
| FaxNumber: | 5052724545 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | MSC10 5590 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052721745 | ||||||||
| FaxNumber: | 5052728699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 03/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 59810 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3349537 | 05 | TN | MEDICAID |