Provider Demographics
NPI:1033480983
Name:KENNEDY, DINA (LMT)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16400 US HIGHWAY 331 S STE B2
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32439-4192
Mailing Address - Country:US
Mailing Address - Phone:850-307-2617
Mailing Address - Fax:
Practice Address - Street 1:299 BAY GROVE RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:FL
Practice Address - Zip Code:32439-4833
Practice Address - Country:US
Practice Address - Phone:850-307-2617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA52443225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist