Provider Demographics
NPI:1013000306
Name:KENNEDY, AMY REBECCA (RD)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:REBECCA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:REBECCA
Other - Last Name:PROBASCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:600 MCCLELLAN ST
Mailing Address - Street 2:2 EAST
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-1009
Mailing Address - Country:US
Mailing Address - Phone:518-347-5421
Mailing Address - Fax:
Practice Address - Street 1:600 MCCLELLAN ST
Practice Address - Street 2:2 EAST
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12304-1009
Practice Address - Country:US
Practice Address - Phone:518-347-5421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006413133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
10135959OtherCDPHP
NYRB6141Medicare PIN