Healthcare Provider Details

I. General information

NPI: 1962130682
Provider Name (Legal Business Name): KENNEDY LOGAN CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 HOPE ST
PROVIDENCE RI
02906-1631
US

IV. Provider business mailing address

35 MILES AVE
EAST PROVIDENCE RI
02914-2143
US

V. Phone/Fax

Practice location:
  • Phone: 401-373-3224
  • Fax: 401-210-2155
Mailing address:
  • Phone: 405-317-3240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: