| Doctor Name: | MRS. MARY ELLEN KENWORTHY |
| NPI Number: | 1205123361 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | D.O. |
| License Number: | 5101019264 |
| Business Practice Address: | 50 North Perry Street Pontiac, MI - 48342 |
| Business Phone Number: | 2762238350 |
| Business Fax Number: | |
| Mailing Address: | 50 North Perry Street, PONTIAC |
| State: | MI |
| Postal Code: | 48342 |
| Phone Number: | 2483385393 |
| Fax Number: | 2483385567 |
| NPI Enumeration Date: | 07/08/2011 |
| NPI Last Update Date: | 05/16/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | 5101019264 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Student, Health Care |
| Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |