Provider Demographics
NPI:1093562837
Name:KENNY, KIMBERLY SHANTALE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SHANTALE
Last Name:KENNY
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 1:802 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-4927
Mailing Address - Country:US
Mailing Address - Phone:910-581-7745
Mailing Address - Fax:
Practice Address - Street 1:802 DAVIS ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-4927
Practice Address - Country:US
Practice Address - Phone:910-581-7745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
NC11806225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist