Provider Demographics
NPI:1508852989
Name:KENNEDY, SHELLY C (DC)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:C
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-2403
Mailing Address - Country:US
Mailing Address - Phone:941-929-0020
Mailing Address - Fax:941-921-7843
Practice Address - Street 1:4155 CLARK RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-2403
Practice Address - Country:US
Practice Address - Phone:941-929-0020
Practice Address - Fax:941-921-7843
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006233111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22563OtherBCBS
FL22563OtherBCBS
FL09443Medicare UPIN