Healthcare Provider Details

I. General information

NPI: 1659291532
Provider Name (Legal Business Name): KENNEDY FACIAL PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 LAKES BLVD
BREAUX BRIDGE LA
70517-3240
US

IV. Provider business mailing address

550 LAKES BLVD
BREAUX BRIDGE LA
70517-3240
US

V. Phone/Fax

Practice location:
  • Phone: 337-761-3361
  • Fax:
Mailing address:
  • Phone: 337-761-3361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PAIGE MARIE KENNEDY
Title or Position: OWNER, FACIAL PLASTIC SURGEON
Credential: MD
Phone: 337-781-9728