Provider Demographics
NPI:1366676462
Name:KENNEDY, BOBBI GABRIELE (IDMT)
Entity Type:Individual
Prefix:
First Name:BOBBI
Middle Name:GABRIELE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 NE CORNFOOT ROAD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218
Mailing Address - Country:US
Mailing Address - Phone:503-335-4557
Mailing Address - Fax:503-335-5609
Practice Address - Street 1:6801 NE CORNFOOT ROAD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218
Practice Address - Country:US
Practice Address - Phone:503-335-4557
Practice Address - Fax:503-335-5609
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians