Provider Demographics
NPI:1124167861
Name:KENNEDY, ELIZABETH ELLEN
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ELLEN
Last Name:KENNEDY
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 1:2 HAMMOND PL
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-2232
Mailing Address - Country:US
Mailing Address - Phone:781-395-8616
Mailing Address - Fax:617-626-9591
Practice Address - Street 1:75 FENWOOD RD.
Practice Address - Street 2:MASSACHUSETTS MENTAL HEALTH CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-626-9326
Practice Address - Fax:617-626-9578
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA146061363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAKENP4208Medicare ID - Type Unspecified
MAP93120Medicare UPIN