Provider Demographics
NPI:1992316574
Name:KENNEDY, EDNA MORAA
Entity type:Individual
Prefix:DR
First Name:EDNA
Middle Name:MORAA
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 1:1633 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-2922
Mailing Address - Country:US
Mailing Address - Phone:973-761-7391
Mailing Address - Fax:973-761-7036
Practice Address - Street 1:1633 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-2922
Practice Address - Country:US
Practice Address - Phone:973-761-7391
Practice Address - Fax:973-761-7036
Is Sole Proprietor?:No
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RJ08036183500000X
NJ28RI03988000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist