Provider Demographics
NPI:1033792833
Name:NULL, KENNEDI
Entity Type:Individual
Prefix:
First Name:KENNEDI
Middle Name:
Last Name:NULL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 585
Mailing Address - Street 2:
Mailing Address - City:WHITE SULPHUR SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:24986-0585
Mailing Address - Country:US
Mailing Address - Phone:304-731-1168
Mailing Address - Fax:
Practice Address - Street 1:165 BURDETTE WAY
Practice Address - Street 2:
Practice Address - City:WHITE SULPHER SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:24986
Practice Address - Country:US
Practice Address - Phone:304-731-1168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker