1831795764 NPI number — EBONY NICOLE KENNEDY MASTERED LEVEL

Table of content: EBONY NICOLE KENNEDY MASTERED LEVEL (NPI 1831795764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831795764 NPI number — EBONY NICOLE KENNEDY MASTERED LEVEL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
EBONY
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MASTERED LEVEL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831795764
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1639 RYAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CHARLES
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70601-5948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-360-6199
Provider Business Mailing Address Fax Number:
337-602-6392

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1639 RYAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70601-5948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-360-6199
Provider Business Practice Location Address Fax Number:
337-602-6392
Provider Enumeration Date:
12/07/2020

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: K530-214-84-877-0 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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