Provider Demographics
NPI:1043720949
Name:KENNA, MALLORY C
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:C
Last Name:KENNA
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 1:14424 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-6433
Mailing Address - Country:US
Mailing Address - Phone:320-630-8345
Mailing Address - Fax:
Practice Address - Street 1:14424 OAK RIDGE DR
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-6433
Practice Address - Country:US
Practice Address - Phone:320-630-8345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer