Provider Demographics
NPI:1982857900
Name:KENNEDY, TERRI
Entity Type:Individual
Prefix:
First Name:TERRI
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 1:120 WAHL AVE
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11096-1316
Mailing Address - Country:US
Mailing Address - Phone:516-239-1858
Mailing Address - Fax:
Practice Address - Street 1:120 WAHL AVE
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:NY
Practice Address - Zip Code:11096-1316
Practice Address - Country:US
Practice Address - Phone:516-239-1858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182033164W00000X
NY654312163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163W00000XNursing Service ProvidersRegistered Nurse