Provider Demographics
NPI:1013427970
Name:KENNY, MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KENNY
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 1:30 WINTER ST FL 9
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02108-4720
Mailing Address - Country:US
Mailing Address - Phone:617-426-0600
Mailing Address - Fax:
Practice Address - Street 1:529 MAIN ST STE 216
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-1122
Practice Address - Country:US
Practice Address - Phone:617-426-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2261585207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine