Provider Demographics
NPI:1063113447
Name:FRASIER, KENNEDY S
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:S
Last Name:FRASIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3884 DRIPPING SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-9715
Mailing Address - Country:US
Mailing Address - Phone:270-590-5254
Mailing Address - Fax:
Practice Address - Street 1:3884 DRIPPING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-9715
Practice Address - Country:US
Practice Address - Phone:270-590-5254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252Y00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No252Y00000XAgenciesEarly Intervention Provider Agency