Provider Demographics
NPI:1528145398
Name:KENNEDY, NICOLE CELESTE (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CELESTE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2253
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-2253
Mailing Address - Country:US
Mailing Address - Phone:843-857-9400
Mailing Address - Fax:
Practice Address - Street 1:612 W CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4410
Practice Address - Country:US
Practice Address - Phone:843-857-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1603225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist