1629745534 NPI number — MRS. KENNEDY MARIE CASSIDY APRN

Table of content: MRS. KENNEDY MARIE CASSIDY APRN (NPI 1629745534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629745534 NPI number — MRS. KENNEDY MARIE CASSIDY APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASSIDY
Provider First Name:
KENNEDY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KRAKAR
Provider Other First Name:
KENNEDY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629745534
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1016 KELLY CREEK CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVIEDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32765-5702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-761-5561
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1016 KELLY CREEK CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OVIEDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32765-5702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-761-5561
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  11014372 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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