Healthcare Provider Details

I. General information

NPI: 1649852765
Provider Name (Legal Business Name): VERONICA M KENNEDY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2021
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79260 CAMINO ROSADA
LA QUINTA CA
92253-5935
US

IV. Provider business mailing address

79260 CAMINO ROSADA
LA QUINTA CA
92253-5935
US

V. Phone/Fax

Practice location:
  • Phone: 760-821-3822
  • Fax:
Mailing address:
  • Phone: 760-821-3822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2160896
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: