Provider Demographics
NPI:1043972227
Name:KENNEDY, KEIRSTEN
Entity Type:Individual
Prefix:
First Name:KEIRSTEN
Middle Name:
Last Name:KENNEDY
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 1:6 GREEN LEAF TER
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-3624
Mailing Address - Country:US
Mailing Address - Phone:540-840-7503
Mailing Address - Fax:
Practice Address - Street 1:402 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:VA
Practice Address - Zip Code:22812-1511
Practice Address - Country:US
Practice Address - Phone:540-828-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program