Provider Demographics
NPI:1235149931
Name:KENNEDY, STACY (MPH,RD,LDN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MPH,RD,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3722
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1404 COMMONWEALTH AVE
Practice Address - Street 2:#4
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3722
Practice Address - Country:US
Practice Address - Phone:617-713-2835
Practice Address - Fax:617-632-4095
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1769133V00000X
NH1338133V00000X
MA1287133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered