Provider Demographics
NPI:1689208571
Name:KENNY, SAGE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:SAGE
Middle Name:ANN
Last Name:KENNY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 WATER ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06854-3754
Mailing Address - Country:US
Mailing Address - Phone:203-545-4032
Mailing Address - Fax:
Practice Address - Street 1:149 WATER ST APT 32
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06854-3758
Practice Address - Country:US
Practice Address - Phone:203-545-4032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4753363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical