Provider Demographics
NPI:1497101844
Name:KENNEDY, SUSANNE MICHELLE
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:MICHELLE
Last Name:KENNEDY
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 1:58967 BUSINESS CENTER DR
Mailing Address - Street 2:SUITES C,D
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-7308
Mailing Address - Country:US
Mailing Address - Phone:760-369-3130
Mailing Address - Fax:760-365-2695
Practice Address - Street 1:58967 BUSINESS CENTER DR
Practice Address - Street 2:SUITES C,D
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7308
Practice Address - Country:US
Practice Address - Phone:760-369-3130
Practice Address - Fax:760-365-2695
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker