Provider Demographics
NPI:1275233793
Name:KENNEDY, MELISSA LYNN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
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 1:200 NEW RIVER TOWN CTR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:96 COLONIAL MANOR DR
Practice Address - Street 2:
Practice Address - City:JUMPING BRANCH
Practice Address - State:WV
Practice Address - Zip Code:25969
Practice Address - Country:US
Practice Address - Phone:304-466-0076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker