Provider Demographics
NPI:1730701178
Name:KENNEDY, MISTY NICOLE
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:NICOLE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 CROW FARM RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:LA
Mailing Address - Zip Code:71260-4129
Mailing Address - Country:US
Mailing Address - Phone:318-805-6702
Mailing Address - Fax:
Practice Address - Street 1:442 E FRENCHMANS BEND RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-8852
Practice Address - Country:US
Practice Address - Phone:318-503-9789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA307751225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist