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General NPI Number Information
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NPI Number | 1902217607
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Entity Type | Organization
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Legal Business Name | KENNEDY MEDICAL GROUP PRACTICE, P.C. D/B/A KENNEDY HEALTH ALLIANCE
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Dates
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Enumeration Date | 05/15/2014
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Last Update Date | 08/18/2014
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Provider Practice Location Address
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Address Line | 1300 LIBERTY PL
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City | SICKLERVILLE
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State | NJ
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Zip | 08081-5710
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Country | US
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Telephone | 856-262-8100
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Fax |
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Provider Business Mailing Address
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Address Line | 1300 LIBERTY PL
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City | SICKLERVILLE
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State | NJ
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Zip | 08081-5710
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Country | US
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Telephone | 856-262-8100
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Fax | 856-885-6859
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Authorized Official
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Title or Position | NP
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Name | AMANDA MARIE FOX
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Credential | FNP-C
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Telephone | 856-262-8100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 26NJ00504300
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License Number State | NJ
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