Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 1-116711 | AL |
NPI | 1003299074 |
---|---|
Provider Name | Mamie Kennedy |
First Address | Brewton, AL 36426-1500 |
Second Address | Brewton, AL 36426-1500 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2015 |
Last Update Date | 08/07/2015 |