Healthcare Provider Details

I. General information

NPI: 1982069860
Provider Name (Legal Business Name): ELIZABETH KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 POTTER BLVD
BRIGHTWATERS NY
11718-1830
US

IV. Provider business mailing address

23 ROOSEVELT DR
BETHPAGE NY
11714-5537
US

V. Phone/Fax

Practice location:
  • Phone: 631-376-0055
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: