Provider Demographics
NPI:1114576386
Name:KENNEDY, ANTWAINE MAURICE
Entity Type:Individual
Prefix:
First Name:ANTWAINE
Middle Name:MAURICE
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24400 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-2313
Mailing Address - Country:US
Mailing Address - Phone:216-849-1860
Mailing Address - Fax:
Practice Address - Street 1:24400 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44123-2313
Practice Address - Country:US
Practice Address - Phone:216-849-1860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide