Provider Demographics
NPI:1134692601
Name:KENNEDY, TRIRETTA
Entity Type:Individual
Prefix:
First Name:TRIRETTA
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 1:3751 STOCKER ST
Mailing Address - Street 2:
Mailing Address - City:VIEW PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90008-5101
Mailing Address - Country:US
Mailing Address - Phone:323-298-3680
Mailing Address - Fax:323-292-0053
Practice Address - Street 1:3751 STOCKER ST
Practice Address - Street 2:
Practice Address - City:VIEW PARK
Practice Address - State:CA
Practice Address - Zip Code:90008-5101
Practice Address - Country:US
Practice Address - Phone:323-298-3680
Practice Address - Fax:323-292-0053
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker