Provider Demographics
NPI:1487119210
Name:ROBERTS, KENNEDY LEIGH
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:LEIGH
Last Name:ROBERTS
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 1:695 RASLEYTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PEN ARGYL
Mailing Address - State:PA
Mailing Address - Zip Code:18072-9755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:695 RASLEYTOWN RD
Practice Address - Street 2:
Practice Address - City:PEN ARGYL
Practice Address - State:PA
Practice Address - Zip Code:18072-9755
Practice Address - Country:US
Practice Address - Phone:484-225-3065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program