Individual
KAREN KENNICOTT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
5901 HARPER DR NE, PMG NORTHSIDE, ALBUQUERQUE, NM 87109-3587
(505) 823-8888
(505) 823-8275
Mailing address
PO BOX 26666, PHS PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-5356
(505) 923-5354
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
8792
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
39537
—
NM
Enumeration date
03/02/2007
Last updated
07/15/2008
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