Provider Demographics
NPI:1972811610
Name:KENNEDY, SANDRA (PT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:FORKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:222 ACACIA ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3800
Mailing Address - Country:US
Mailing Address - Phone:707-421-0418
Mailing Address - Fax:707-434-9725
Practice Address - Street 1:222 ACACIA ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3800
Practice Address - Country:US
Practice Address - Phone:707-421-0418
Practice Address - Fax:707-434-9725
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21453225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist