Healthcare Provider Details

I. General information

NPI: 1578966982
Provider Name (Legal Business Name): MELISSA FAY KENNEDY AA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA ELEANOR FAY AA-C

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 W SUNRISE BLVD
PLANTATION FL
33322-4113
US

IV. Provider business mailing address

7700 W SUNRISE BLVD
PLANTATION FL
33322-4113
US

V. Phone/Fax

Practice location:
  • Phone: 549-396-7669
  • Fax:
Mailing address:
  • Phone: 954-838-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA245
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: