Individual
EBONY NICOLE KENNEDY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MASTERED LEVEL
Contact information
Practice address
1639 RYAN ST, LAKE CHARLES, LA 70601-5948
(985) 360-6199
(337) 602-6392
Mailing address
1639 RYAN ST, LAKE CHARLES, LA 70601-5948
(985) 360-6199
(337) 602-6392
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
K530-214-84-877-0
—
FL
Enumeration date
12/07/2020
Last updated
12/07/2020
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