Provider Demographics
NPI:1093247603
Name:KENNAMER, BROOKE TATIANA (DO)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:TATIANA
Last Name:KENNAMER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BOSTON MEDICAL CTR PL
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2908
Mailing Address - Country:US
Mailing Address - Phone:617-638-8000
Mailing Address - Fax:
Practice Address - Street 1:609 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2515
Practice Address - Country:US
Practice Address - Phone:617-638-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-02
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAUNKNOWN207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology