Provider Demographics
NPI:1447053905
Name:KENNEDY, TYLER BRIAN
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:BRIAN
Last Name:KENNEDY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3357 CARPENTER CT
Mailing Address - Street 2:
Mailing Address - City:GARNET VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19060-1710
Mailing Address - Country:US
Mailing Address - Phone:610-675-4074
Mailing Address - Fax:
Practice Address - Street 1:101 STADIUM DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-7911
Practice Address - Country:US
Practice Address - Phone:304-598-4850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program