=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730701178
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISTY NICOLE KENNEDY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2020
-----------------------------------------------------
Last Update Date | 05/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 442 E FRENCHMANS BEND RD
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71203-8852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-503-9789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2712 CROW FARM RD
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71260-4129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-805-6702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 307751
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------