Healthcare Provider Details

I. General information

NPI: 1467316877
Provider Name (Legal Business Name): KENNEDY WILLEMARCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5125 COUNTY ROAD 101 STE 300
MINNETONKA MN
55345-4157
US

IV. Provider business mailing address

5125 COUNTY ROAD 101 STE 300
MINNETONKA MN
55345-4157
US

V. Phone/Fax

Practice location:
  • Phone: 952-932-7277
  • Fax: 952-932-9827
Mailing address:
  • Phone: 952-932-7277
  • Fax: 952-932-9827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number32169
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: