Healthcare Provider Details

I. General information

NPI: 1134308455
Provider Name (Legal Business Name): MICHELLE L KENNEDY CST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2007
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 CRYSTAL DR
MADEIRA BEACH FL
33708-2373
US

IV. Provider business mailing address

516 CRYSTAL DR
MADEIRA BEACH FL
33708-2373
US

V. Phone/Fax

Practice location:
  • Phone: 727-442-6086
  • Fax: 888-329-6432
Mailing address:
  • Phone: 727-442-6086
  • Fax: 888-329-6432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: