Provider Demographics
NPI:1659037117
Name:KENNEDY, AUDREY MARILYN
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:MARILYN
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 1:139 E OLD TRENTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5945
Mailing Address - Country:US
Mailing Address - Phone:931-444-1449
Mailing Address - Fax:
Practice Address - Street 1:7049 TAYLORSVILLE RD STE A
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-3190
Practice Address - Country:US
Practice Address - Phone:937-233-1755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.026916225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist