Provider Demographics
NPI:1114231750
Name:KENNA, INGRID (PTA)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:KENNA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1865 PACE DR NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-7070
Mailing Address - Country:US
Mailing Address - Phone:321-298-8594
Mailing Address - Fax:
Practice Address - Street 1:3201 W COMMERCIAL BLVD
Practice Address - Street 2:116
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-3440
Practice Address - Country:US
Practice Address - Phone:954-332-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA1597225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant