Provider Demographics
NPI:1861983983
Name:EBERSOLE, KENNEDIE
Entity type:Individual
Prefix:
First Name:KENNEDIE
Middle Name:
Last Name:EBERSOLE
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 1:248 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16371-1174
Mailing Address - Country:US
Mailing Address - Phone:814-706-9310
Mailing Address - Fax:
Practice Address - Street 1:248 E MAIN ST
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16371-1174
Practice Address - Country:US
Practice Address - Phone:814-706-9310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program