Healthcare Provider Details

I. General information

NPI: 1578677068
Provider Name (Legal Business Name): JULIE RENEE KENNON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

749 IRVINE RD
CLAY CITY KY
40312-9732
US

IV. Provider business mailing address

PO BOX 636493
CINCINNATI OH
45263-6493
US

V. Phone/Fax

Practice location:
  • Phone: 606-663-2153
  • Fax: 606-663-7966
Mailing address:
  • Phone: 513-981-5130
  • Fax: 513-981-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33379
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: