Healthcare Provider Details

I. General information

NPI: 1598183444
Provider Name (Legal Business Name): PATRICIA LYNN KENNEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS PATRICIA LYNN GLLI

II. Dates (important events)

Enumeration Date: 03/28/2014
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 S FAIRMONT AVE
LODI CA
95240-5100
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-3333
  • Fax: 209-369-2641
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA156269
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA156269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: