Provider Demographics
NPI:1053122499
Name:KENNEDY, ROSTEN
Entity type:Individual
Prefix:
First Name:ROSTEN
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 394
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98850-0394
Mailing Address - Country:US
Mailing Address - Phone:509-855-6800
Mailing Address - Fax:
Practice Address - Street 1:2026 DIVISION ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-8058
Practice Address - Country:US
Practice Address - Phone:800-457-9303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA609805473747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant