Healthcare Provider Details

I. General information

NPI: 1285983098
Provider Name (Legal Business Name): MARY ANN KENNESON, M.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 03/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1895 KINGSLEY AVE STE 903
ORANGE PARK FL
32073-4410
US

IV. Provider business mailing address

1895 KINGSLEY AVE STE 903
ORANGE PARK FL
32073-4410
US

V. Phone/Fax

Practice location:
  • Phone: 904-644-8353
  • Fax: 904-644-8289
Mailing address:
  • Phone: 904-644-8353
  • Fax: 904-644-8289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME92864
License Number StateFL

VIII. Authorized Official

Name: DR. MARYANN KENNESON
Title or Position: PRESIDENT
Credential: MD
Phone: 859-421-3759