Provider Demographics
NPI:1003971995
Name:KENNEFICK, ANN N (NP)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:N
Last Name:KENNEFICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 WASHBURN AVE
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-5263
Mailing Address - Country:US
Mailing Address - Phone:781-237-7938
Mailing Address - Fax:
Practice Address - Street 1:332 WASHINGTON ST
Practice Address - Street 2:SUITE 380
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-6219
Practice Address - Country:US
Practice Address - Phone:781-237-4194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA133500363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP3334OtherBLUE CROSS
MANP3334Medicare UPIN