Provider Demographics
NPI:1487693644
Name:KENNEDY, BROOKE (APRN)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-312-8258
Mailing Address - Fax:337-312-6708
Practice Address - Street 1:501 DR MICHAEL DEBAKEY DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5724
Practice Address - Country:US
Practice Address - Phone:337-419-1958
Practice Address - Fax:337-419-1947
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN104229 AP04899363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1706329Medicaid
LA1706329Medicaid
Q70547Medicare UPIN
4H8887460Medicare PIN