Healthcare Provider Details

I. General information

NPI: 1225955545
Provider Name (Legal Business Name): KENNEDI WICKHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 ANNAPOLIS RD STE 315
GLENN DALE MD
20769-9182
US

IV. Provider business mailing address

13917 ROCKINGHAM RD
GERMANTOWN MD
20874-2230
US

V. Phone/Fax

Practice location:
  • Phone: 301-249-0970
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberC0010599
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: