Healthcare Provider Details

I. General information

NPI: 1821226499
Provider Name (Legal Business Name): HEATHER AINE KENNEDY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 CORTINA DR
ORLAND CA
95963-1699
US

IV. Provider business mailing address

1513 PARK AVE
COLUMBUS WI
53925-1618
US

V. Phone/Fax

Practice location:
  • Phone: 530-865-5544
  • Fax: 530-865-9209
Mailing address:
  • Phone: 920-623-9611
  • Fax: 920-623-1788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number58094-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: