Provider Demographics
NPI:1184223257
Name:KENNEDY, DAN
Entity Type:Individual
Prefix:MR
First Name:DAN
Middle Name:
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 1:479 MASON ST STE 109
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-4541
Mailing Address - Country:US
Mailing Address - Phone:707-249-9247
Mailing Address - Fax:707-471-4028
Practice Address - Street 1:479 MASON ST STE 109
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-4541
Practice Address - Country:US
Practice Address - Phone:707-249-9247
Practice Address - Fax:707-471-4028
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator