Provider Demographics
NPI:1134812118
Name:KENNEDY, KRYSTAL
Entity type:Individual
Prefix:MRS
First Name:KRYSTAL
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 1:297 INDEPENDENCE BLVD
Mailing Address - Street 2:PEMBROKE 6, SUITE 300
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462
Mailing Address - Country:US
Mailing Address - Phone:757-390-1736
Mailing Address - Fax:
Practice Address - Street 1:297 INDEPENDENCE BLVD
Practice Address - Street 2:PEMBROKE 6, SUITE 300
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462
Practice Address - Country:US
Practice Address - Phone:757-390-1736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09060100041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical