Provider Demographics
NPI:1346815354
Name:KENNEY, MARCI J
Entity Type:Individual
Prefix:
First Name:MARCI
Middle Name:J
Last Name:KENNEY
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 1:6363 E 500TH ST
Mailing Address - Street 2:
Mailing Address - City:LYNN CENTER
Mailing Address - State:IL
Mailing Address - Zip Code:61262-9704
Mailing Address - Country:US
Mailing Address - Phone:309-737-0342
Mailing Address - Fax:
Practice Address - Street 1:201 11TH AVENUE
Practice Address - Street 2:
Practice Address - City:ORION
Practice Address - State:IL
Practice Address - Zip Code:61273
Practice Address - Country:US
Practice Address - Phone:309-526-8008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-039232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist