Provider Demographics
NPI:1578966982
Name:KENNEDY, MELISSA FAY (AA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:FAY
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:AA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ELEANOR
Other - Last Name:FAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA-C
Mailing Address - Street 1:7700 W SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-4113
Mailing Address - Country:US
Mailing Address - Phone:954-838-2371
Mailing Address - Fax:
Practice Address - Street 1:7700 W SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-4113
Practice Address - Country:US
Practice Address - Phone:549-396-7669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA245367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant