Provider Demographics
NPI:1558513226
Name:KENNEDY, ROBERTA LEE
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:LEE
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 1:2700 ROBERT T. LONGWAY BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503
Mailing Address - Country:US
Mailing Address - Phone:810-235-2599
Mailing Address - Fax:
Practice Address - Street 1:2700 ROBERT T. LONGWAY BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503
Practice Address - Country:US
Practice Address - Phone:810-235-2599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704140071364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOB514740OtherBLUE CROSS GROUP
MIOP23940Medicare PIN