Provider Demographics
NPI:1841640547
Name:KENNEDY, NERISSA NICOLE (PA)
Entity type:Individual
Prefix:MS
First Name:NERISSA
Middle Name:NICOLE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1 HARMON PLZ FL 3
Mailing Address - Street 2:
Mailing Address - City:SECAUCUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07094-2803
Mailing Address - Country:US
Mailing Address - Phone:551-257-7039
Mailing Address - Fax:
Practice Address - Street 1:36 NEWARK AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-4119
Practice Address - Country:US
Practice Address - Phone:973-429-2209
Practice Address - Fax:973-429-2210
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MP00398500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant