Healthcare Provider Details

I. General information

NPI: 1023046489
Provider Name (Legal Business Name): SUSAN REIN KENNEDY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 W HURON ST
PONTIAC MI
48342-2120
US

IV. Provider business mailing address

35 W HURON ST
PONTIAC MI
48342-2120
US

V. Phone/Fax

Practice location:
  • Phone: 248-745-4900
  • Fax: 248-745-6872
Mailing address:
  • Phone: 248-745-4900
  • Fax: 248-745-6872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704085991
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: