1972621068 NPI number — JOAN MARGARET KENNEDY P.T.

Table of content: JOAN MARGARET KENNEDY P.T. (NPI 1972621068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972621068 NPI number — JOAN MARGARET KENNEDY P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
JOAN
Provider Middle Name:
MARGARET
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972621068
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 17334
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21297-1334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-443-6717
Provider Business Mailing Address Fax Number:
703-443-8643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224D CORNWALL ST NW
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20176-2700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-443-2223
Provider Business Practice Location Address Fax Number:
703-443-2690
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2305202642 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1972621068 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00948393 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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