Provider Demographics
NPI:1730171406
Name:KENNISTON, NANCY (LPT)
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:
Last Name:KENNISTON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-9723
Mailing Address - Country:US
Mailing Address - Phone:724-588-3330
Mailing Address - Fax:724-588-1338
Practice Address - Street 1:41 6TH AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125-9723
Practice Address - Country:US
Practice Address - Phone:724-588-3330
Practice Address - Fax:724-588-1338
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA003285L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010073950001Medicaid
PA1010073950001Medicaid