Provider Demographics
NPI:1962087395
Name:KENNEDY, LYDIA LIZETH (NUTRITIONIST, IBCLC)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:LIZETH
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NUTRITIONIST, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 E ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-2422
Mailing Address - Country:US
Mailing Address - Phone:417-406-6107
Mailing Address - Fax:
Practice Address - Street 1:4750 E ROYAL DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65809-2422
Practice Address - Country:US
Practice Address - Phone:417-406-6107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133NN1002X, 174N00000X
MOL-302127174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty