Provider Demographics
NPI:1356438873
Name:KENNELLY, CYNTHIA MARY (DC)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MARY
Last Name:KENNELLY
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 1:131 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:PA
Mailing Address - Zip Code:18644-1607
Mailing Address - Country:US
Mailing Address - Phone:570-693-9393
Mailing Address - Fax:570-693-2703
Practice Address - Street 1:131 W 8TH ST
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:PA
Practice Address - Zip Code:18644-1607
Practice Address - Country:US
Practice Address - Phone:570-693-9393
Practice Address - Fax:570-693-2703
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC004703L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA691197OtherBLUE SHIELD
PA001432305001Medicaid
PA691197OtherBLUE SHIELD
PAKE691197Medicare ID - Type Unspecified