Provider Demographics
NPI:1740893098
Name:KENNEDY, ROBERT DALE
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:DALE
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 MITCHELL BRANCH
Mailing Address - Street 2:
Mailing Address - City:RED JACKET
Mailing Address - State:WV
Mailing Address - Zip Code:25692
Mailing Address - Country:US
Mailing Address - Phone:304-426-4393
Mailing Address - Fax:
Practice Address - Street 1:460 MITCHELL BRANCH
Practice Address - Street 2:
Practice Address - City:RED JACKET
Practice Address - State:WV
Practice Address - Zip Code:25692
Practice Address - Country:US
Practice Address - Phone:304-426-4393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant