Provider Demographics
NPI:1568423549
Name:KENNEDY, VANNETA K (PT, DPT)
Entity Type:Individual
Prefix:MISS
First Name:VANNETA
Middle Name:K
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 PILOT HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:10640 CHARTER HILL CT
Practice Address - Street 2:SUITE 102
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-7749
Practice Address - Country:US
Practice Address - Phone:804-550-5730
Practice Address - Fax:804-550-5733
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204413225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00245786OtherRAILROAD MEDICARE
VA010192153Medicaid
VA192931OtherBCBS PHYSICAL THERAPY
7867723OtherAETNA
VA008515T54Medicare PIN
VA192931OtherBCBS PHYSICAL THERAPY