Provider Demographics
NPI:1639939234
Name:KENNON, MARVA L (PCA)
Entity Type:Individual
Prefix:
First Name:MARVA
Middle Name:L
Last Name:KENNON
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 E 156TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-3069
Mailing Address - Country:US
Mailing Address - Phone:216-242-7943
Mailing Address - Fax:
Practice Address - Street 1:789 E 156TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-3069
Practice Address - Country:US
Practice Address - Phone:216-242-7943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPX401546374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide