Provider Demographics
NPI:1891836110
Name:KENNEDY, MICHELLE LYNN (NP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 MAIN ST
Mailing Address - Street 2:ATTN: CREDENTIALING DPT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2718
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:860-638-6601
Practice Address - Street 1:51 N ELM ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1511
Practice Address - Country:US
Practice Address - Phone:203-574-4000
Practice Address - Fax:203-574-4003
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16084363LF0000X
CT3620363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236346Medicaid