Provider Demographics
NPI:1952720187
Name:KENNEY, MARYLYN (MOT)
Entity Type:Individual
Prefix:MS
First Name:MARYLYN
Middle Name:
Last Name:KENNEY
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 WILLARD DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-4228
Mailing Address - Country:US
Mailing Address - Phone:434-979-8628
Mailing Address - Fax:
Practice Address - Street 1:1102 ROSE HILL DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-5128
Practice Address - Country:US
Practice Address - Phone:434-979-8628
Practice Address - Fax:434-979-8536
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119006287174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist