Healthcare Provider Details

I. General information

NPI: 1164689949
Provider Name (Legal Business Name): TINA M KENNEDY M.B.A. R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2522 W WACKERLY ST STE B
MIDLAND MI
48640-6921
US

IV. Provider business mailing address

PO BOX 188
ALMA MI
48801-0188
US

V. Phone/Fax

Practice location:
  • Phone: 989-839-7770
  • Fax: 989-839-7777
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: