Provider Demographics
NPI:1235935123
Name:KENNEDY, JOHANNAH ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:JOHANNAH
Middle Name:ROSE
Last Name:KENNEDY
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29201 TELEGRAPH RD STE 500
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-7648
Mailing Address - Country:US
Mailing Address - Phone:248-569-5985
Mailing Address - Fax:
Practice Address - Street 1:29201 TELEGRAPH RD STE 500
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-7648
Practice Address - Country:US
Practice Address - Phone:248-569-5985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601013016363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant