Provider Demographics
NPI:1255997581
Name:KENNEDY, KAITLYN ERIN
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ERIN
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 1:47 EAST ST
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:CT
Mailing Address - Zip Code:06248-1309
Mailing Address - Country:US
Mailing Address - Phone:860-682-4040
Mailing Address - Fax:
Practice Address - Street 1:322 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14608-1162
Practice Address - Country:US
Practice Address - Phone:585-423-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024151363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant