Provider Demographics
NPI:1063211936
Name:KENNEDY, WAKIA S
Entity type:Individual
Prefix:
First Name:WAKIA
Middle Name:S
Last Name:KENNEDY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 DR MARTIN LUTHER KING JR BLVD APT 107
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-1095
Mailing Address - Country:US
Mailing Address - Phone:908-696-3487
Mailing Address - Fax:
Practice Address - Street 1:751 DR MARTIN LUTHER KING JR BLVD APT 107
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1095
Practice Address - Country:US
Practice Address - Phone:908-696-3487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJK25577758253802172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver