Provider Demographics
NPI:1376155838
Name:KENNEDY, ERIN (LAC)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 CONVENT AVE APT 4B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-4225
Mailing Address - Country:US
Mailing Address - Phone:773-636-5715
Mailing Address - Fax:
Practice Address - Street 1:67 HOME AVE
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-1727
Practice Address - Country:US
Practice Address - Phone:646-470-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006692171100000X
NJ25MZ00145700171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006692OtherNEW YORK STATE ACUPUNCTURE LICENSE
NJ25MZ00145700OtherNEW JERSEY STATE ACUPUNCTURE LICENSE