Provider Demographics
NPI:1265224430
Name:FULLWOOD, KENNEDI KIRSTEN
Entity type:Individual
Prefix:
First Name:KENNEDI
Middle Name:KIRSTEN
Last Name:FULLWOOD
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 1:20 TOMMY TRUE CT
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-4927
Mailing Address - Country:US
Mailing Address - Phone:667-441-5352
Mailing Address - Fax:
Practice Address - Street 1:122 S HAVEN ST UNIT 1F
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2429
Practice Address - Country:US
Practice Address - Phone:410-365-4117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor