Provider Demographics
NPI:1730676263
Name:KENNEDY, SHANNON LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 MAITLAND CROSSING WAY APT 10-301
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-7106
Mailing Address - Country:US
Mailing Address - Phone:412-334-3083
Mailing Address - Fax:
Practice Address - Street 1:995 WESTWOOD SQ STE A
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9049
Practice Address - Country:US
Practice Address - Phone:407-977-7332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA57870225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist