Provider Demographics
NPI:1952662058
Name:KENNEDY, MELISSSA ANN (BA, MS)
Entity Type:Individual
Prefix:MRS
First Name:MELISSSA
Middle Name:ANN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:BA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28B CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3545
Mailing Address - Country:US
Mailing Address - Phone:631-790-4012
Mailing Address - Fax:
Practice Address - Street 1:28B CEDAR AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3545
Practice Address - Country:US
Practice Address - Phone:631-790-4012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist