Provider Demographics
NPI:1679536890
Name:KENNEDY, JAMES R (CRNA)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:R
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:CRNA
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
Mailing Address - Street 2:PO BOX 896138
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6138
Mailing Address - Country:US
Mailing Address - Phone:833-500-9914
Mailing Address - Fax:
Practice Address - Street 1:1104 TUSCULUM BLVD
Practice Address - Street 2:SUITE 114
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4091
Practice Address - Country:US
Practice Address - Phone:423-639-0941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8772367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3600923Medicaid
TN3049637OtherBC/BS
TN3600923Medicare ID - Type Unspecified
TN3600923Medicaid