Provider Demographics
NPI:1972526515
Name:KENNEMORE, TRACY DEWAYNE (PT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:DEWAYNE
Last Name:KENNEMORE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:TRACE
Other - Middle Name:DEWAYNE
Other - Last Name:KENNEMORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:400 DIXIE LEE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:TN
Mailing Address - Zip Code:37347-5672
Mailing Address - Country:US
Mailing Address - Phone:423-837-7536
Mailing Address - Fax:423-837-7538
Practice Address - Street 1:400 DIXIE LEE CENTER RD
Practice Address - Street 2:
Practice Address - City:KIMBALL
Practice Address - State:TN
Practice Address - Zip Code:37347-5672
Practice Address - Country:US
Practice Address - Phone:423-837-7536
Practice Address - Fax:423-837-7538
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000006009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3732180Medicaid
3646106Medicare ID - Type Unspecified