Provider Demographics
NPI:1598229304
Name:KENNEDY, VICTORIA FRANCES (PTA)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:FRANCES
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 PROVIDENCE RESERVE LOOP APT 207
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-2484
Mailing Address - Country:US
Mailing Address - Phone:863-837-7148
Mailing Address - Fax:
Practice Address - Street 1:1213 W STRATFORD RD
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-8091
Practice Address - Country:US
Practice Address - Phone:863-453-6674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28105225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant