Provider Demographics
NPI:1154884500
Name:MASSALEE-KENNEDY, SEYNOR A (NP)
Entity type:Individual
Prefix:
First Name:SEYNOR
Middle Name:A
Last Name:MASSALEE-KENNEDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SEYNOR
Other - Middle Name:
Other - Last Name:MASSALEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6300 SADIE LN
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48111-5259
Mailing Address - Country:US
Mailing Address - Phone:313-208-4588
Mailing Address - Fax:
Practice Address - Street 1:6300 SADIE LN
Practice Address - Street 2:
Practice Address - City:VAN BUREN TWP
Practice Address - State:MI
Practice Address - Zip Code:48111-5259
Practice Address - Country:US
Practice Address - Phone:313-208-4588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704321588363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner