Healthcare Provider Details

I. General information

NPI: 1124167861
Provider Name (Legal Business Name): MS. ELIZABETH ELLEN KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FENWOOD RD. MASSACHUSETTS MENTAL HEALTH CENTER
BOSTON MA
02115
US

IV. Provider business mailing address

2 HAMMOND PL
MEDFORD MA
02155-2232
US

V. Phone/Fax

Practice location:
  • Phone: 617-626-9326
  • Fax: 617-626-9578
Mailing address:
  • Phone: 781-395-8616
  • Fax: 617-626-9591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number146061
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: