Healthcare Provider Details

I. General information

NPI: 1851366371
Provider Name (Legal Business Name): PAMELA ANN KENNEDY R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

1084 GAUGUIN DR
VIRGINIA BEACH VA
23454-6745
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-0206
  • Fax:
Mailing address:
  • Phone: 757-426-3329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number1019
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number727742
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: