Provider Demographics
NPI:1588361182
Name:THOMPSON, KENNEDY HOPE MASTROLEO
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:HOPE MASTROLEO
Last Name:THOMPSON
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 1:850 VINE ST APT 11E
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-5243
Mailing Address - Country:US
Mailing Address - Phone:315-741-6544
Mailing Address - Fax:
Practice Address - Street 1:7272 HENRY CLAY BLVD APT 107
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3582
Practice Address - Country:US
Practice Address - Phone:315-741-6544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program