Provider Demographics
NPI:1164689949
Name:KENNEDY, TINA M (MBA RD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MBA RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-0188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2522 W WACKERLY ST STE B
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6921
Practice Address - Country:US
Practice Address - Phone:989-839-7770
Practice Address - Fax:989-839-7777
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal