Healthcare Provider Details

I. General information

NPI: 1992071377
Provider Name (Legal Business Name): KELLY KENNEDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 11TH CIR STE 101
VERO BEACH FL
32960-4838
US

IV. Provider business mailing address

3745 11TH CIR STE 101
VERO BEACH FL
32960-4838
US

V. Phone/Fax

Practice location:
  • Phone: 772-567-6412
  • Fax: 321-567-4991
Mailing address:
  • Phone: 772-567-6412
  • Fax: 321-567-4991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number65523
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME160223
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: