Provider Demographics
NPI:1790232940
Name:KENNEDY, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
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 1:1397 S LINDEN RD
Mailing Address - Street 2:STE B
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-4194
Mailing Address - Country:US
Mailing Address - Phone:810-230-9750
Mailing Address - Fax:
Practice Address - Street 1:1397 S LINDEN RD
Practice Address - Street 2:STE B
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-4194
Practice Address - Country:US
Practice Address - Phone:810-230-9750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017625225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist