Provider Demographics
NPI:1588146286
Name:KENNEY, ERIN COLLETTE
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:COLLETTE
Last Name:KENNEY
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 1:6 MASHPEE CIR
Mailing Address - Street 2:
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-2449
Mailing Address - Country:US
Mailing Address - Phone:508-393-8979
Mailing Address - Fax:
Practice Address - Street 1:5 FAN PEIR BOULEVARD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110
Practice Address - Country:US
Practice Address - Phone:774-258-1051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4575133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty