Provider Demographics
NPI:1427879170
Name:KANNENBERG, MEAGAN KIMBERLY GEMENTIZA
Entity type:Individual
Prefix:
First Name:MEAGAN KIMBERLY
Middle Name:GEMENTIZA
Last Name:KANNENBERG
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 1:333 SEVENTH AVE NY NY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001
Mailing Address - Country:US
Mailing Address - Phone:917-415-9310
Mailing Address - Fax:
Practice Address - Street 1:333 SEVENTH AVE NY NY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001
Practice Address - Country:US
Practice Address - Phone:917-415-9310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029561225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist