Provider Demographics
NPI:1932707445
Name:TAMBI, KENNEDY (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:
Last Name:TAMBI
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 GREAT RD STE G1
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-4766
Mailing Address - Country:US
Mailing Address - Phone:978-679-1200
Mailing Address - Fax:
Practice Address - Street 1:289 GREAT RD STE G1
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-4766
Practice Address - Country:US
Practice Address - Phone:978-679-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN237828363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA020860Medicaid