Provider Demographics
NPI:1568405009
Name:KENNEDY, KATHLEEN MARY (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:BERRY
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:48 EDSON RD
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-6435
Mailing Address - Country:US
Mailing Address - Phone:607-765-7075
Mailing Address - Fax:
Practice Address - Street 1:229-231 STATE ST
Practice Address - Street 2:BROOME COUNTY MENTAL HEALTH
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-2756
Practice Address - Country:US
Practice Address - Phone:607-778-1122
Practice Address - Fax:607-778-1164
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF320027363LC1500X
NYF401064363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0320F320027Medicaid
NY0320F320027Medicaid