Provider Demographics
NPI:1629055843
Name:KENNEDY, ELAINE A
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:A
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 1:333 PEARL ST
Mailing Address - Street 2:APT. 18L
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-1609
Mailing Address - Country:US
Mailing Address - Phone:212-374-1099
Mailing Address - Fax:
Practice Address - Street 1:333 PEARL ST
Practice Address - Street 2:APT. 18L
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-1609
Practice Address - Country:US
Practice Address - Phone:212-374-1099
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007885225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ54111Medicare ID - Type Unspecified