Provider Demographics
NPI:1427582980
Name:BOONE-KENNERLY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BOONE-KENNERLY
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 1:414 CLARKSON DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2030
Mailing Address - Country:US
Mailing Address - Phone:202-246-1349
Mailing Address - Fax:
Practice Address - Street 1:414 CLARKSON DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2030
Practice Address - Country:US
Practice Address - Phone:202-246-1349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019009022225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist