Provider Demographics
NPI:1871875716
Name:KENNEDY, SUSAN DANA (REV)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:DANA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:REV
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:DANA
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2 WILD IRIS WAY
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-4169
Mailing Address - Country:US
Mailing Address - Phone:336-323-6688
Mailing Address - Fax:
Practice Address - Street 1:2 WILD IRIS WAY
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-4169
Practice Address - Country:US
Practice Address - Phone:336-456-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYUSA.07.2000.H171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor