Provider Demographics
NPI:1154760312
Name:KENNEDY, SAMANTHA FUGATE (DO)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:FUGATE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ANN
Other - Last Name:FUGATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD
Mailing Address - Street 2:# A109F
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:909 FEE RD STE B119
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824
Practice Address - Country:US
Practice Address - Phone:517-353-3070
Practice Address - Fax:517-432-3603
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010207512084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry