Provider Demographics
NPI:1154963759
Name:MARTIN, KENNESHIA M
Entity type:Individual
Prefix:MS
First Name:KENNESHIA
Middle Name:M
Last Name:MARTIN
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:PO BOX 3836
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33509-3836
Mailing Address - Country:US
Mailing Address - Phone:813-564-5468
Mailing Address - Fax:
Practice Address - Street 1:13135 EARLY RUN LANE
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578
Practice Address - Country:US
Practice Address - Phone:813-564-5468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003385225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant