Provider Demographics
NPI:1477817252
Name:KENNELL, KIMBERLY E (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:E
Last Name:KENNELL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1756 GREENRIDGE CIR S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-5222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:95 TAVERNIER DR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-0676
Practice Address - Country:US
Practice Address - Phone:904-729-6759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA12730235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist