Provider Demographics
NPI:1356431423
Name:KENNEDY, MIRANDA L (DC)
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:L
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 ROUTE 55 STE 5
Mailing Address - Street 2:
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-5047
Mailing Address - Country:US
Mailing Address - Phone:845-473-6620
Mailing Address - Fax:845-473-0407
Practice Address - Street 1:1145 ROUTE 55 STE 5
Practice Address - Street 2:
Practice Address - City:LAGRANGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12540-5047
Practice Address - Country:US
Practice Address - Phone:845-473-6620
Practice Address - Fax:845-473-0407
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010188111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX4M451Medicare ID - Type Unspecified