Provider Demographics
NPI:1699500793
Name:KENNEDY, DANA
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:
Last Name:KENNEDY
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 1:816 ALLE PL
Mailing Address - Street 2:
Mailing Address - City:PINOPOLIS
Mailing Address - State:SC
Mailing Address - Zip Code:29469-5059
Mailing Address - Country:US
Mailing Address - Phone:843-312-1713
Mailing Address - Fax:
Practice Address - Street 1:86 VALLEY HIDEAWAY DR
Practice Address - Street 2:
Practice Address - City:HAYESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28904-9674
Practice Address - Country:US
Practice Address - Phone:828-389-9941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-06
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1736225100000X
NCP-CP034939T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCP034939TOtherCOMPACT LICENSE