Provider Demographics
NPI:1376230946
Name:KENNEDY, MAISON KAI
Entity Type:Individual
Prefix:
First Name:MAISON
Middle Name:KAI
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 SOUTH 40TH STREET
Mailing Address - Street 2:OFFICE OF CLINICAL AFFAIRS-S6A EVANS
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-573-2588
Mailing Address - Fax:
Practice Address - Street 1:240 SOUTH 40TH STREET
Practice Address - Street 2:OFFICE OF CLINICAL AFFAIRS-S6A EVANS
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-573-2588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program