Healthcare Provider Details

I. General information

NPI: 1417538117
Provider Name (Legal Business Name): KENNEDY M ZACCHEO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 LOUISIANA BLVD NE STE 410
ALBUQUERQUE NM
87110-5412
US

IV. Provider business mailing address

265 CLARENDON ST APT 4
BOSTON MA
02116-2012
US

V. Phone/Fax

Practice location:
  • Phone: 505-724-4300
  • Fax: 505-724-4300
Mailing address:
  • Phone: 775-200-4961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2022-0056
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: