Basic Information
| Provider Information | |||||||||
| NPI: | 1164689949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.B.A. R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 188 | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488010188 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2522 W WACKERLY ST STE B | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486406921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898397770 | ||||||||
| FaxNumber: | 9898397777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2008 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1005X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Renal |
No ID Information.