Provider Demographics
NPI:1952693384
Name:KENNEDY, JUDY CAROL (RN)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:CAROL
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 S LUDLOW ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-2610
Mailing Address - Country:US
Mailing Address - Phone:937-208-8816
Mailing Address - Fax:937-208-8828
Practice Address - Street 1:725 S LUDLOW ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2610
Practice Address - Country:US
Practice Address - Phone:937-208-8816
Practice Address - Fax:937-208-8828
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN165323163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRN165323OtherRN LICENSURE