Provider Demographics
NPI:1134512114
Name:KENNELLY, NICOLE MARIE (LMT)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:MARIE
Last Name:KENNELLY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2595 VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:ORIENT
Mailing Address - State:NY
Mailing Address - Zip Code:11957-1469
Mailing Address - Country:US
Mailing Address - Phone:718-683-1905
Mailing Address - Fax:
Practice Address - Street 1:222 MANOR PL
Practice Address - Street 2:
Practice Address - City:GREENPORT
Practice Address - State:NY
Practice Address - Zip Code:11944-1261
Practice Address - Country:US
Practice Address - Phone:631-268-4769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-14
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018013225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist