Provider Demographics
NPI:1164767679
Name:KENNEDY, KELLEY ANNE (MED)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:ANNE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MA
Mailing Address - Zip Code:02038-3323
Mailing Address - Country:US
Mailing Address - Phone:508-520-3875
Mailing Address - Fax:
Practice Address - Street 1:321 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-1750
Practice Address - Country:US
Practice Address - Phone:508-478-0207
Practice Address - Fax:508-634-6984
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist