Provider Demographics
NPI:1609231174
Name:KENNEDY, NICOLE L (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:L
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 SANDUSKY RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-8734
Mailing Address - Country:US
Mailing Address - Phone:567-712-3581
Mailing Address - Fax:
Practice Address - Street 1:5225 SANDUSKY RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-8734
Practice Address - Country:US
Practice Address - Phone:567-712-3581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03806174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist