Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 003678 | CT |
NPI | 1073650016 |
---|---|
Provider Name | Pamela Kennedy |
First Address | Bridgeport, CT 06608-2335 |
Second Address | Bridgeport, CT 06608-2335 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
184905 | (02) | CT |
9175945 | (02) | CT |