Healthcare Provider Details

I. General information

NPI: 1992739650
Provider Name (Legal Business Name): KELLI A KENNEDY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 MILL ST, BLD E, SUITE 17 HCS-HANOVER PEDIATRICS
HANOVER MA
02339
US

IV. Provider business mailing address

51 MILL ST BLDG. E, #17
HANOVER MA
02339-1641
US

V. Phone/Fax

Practice location:
  • Phone: 781-826-2131
  • Fax:
Mailing address:
  • Phone: 781-826-2131
  • Fax: 781-826-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number228253
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: