Healthcare Provider Details

I. General information

NPI: 1043295876
Provider Name (Legal Business Name): SHALENE ANN KENNEDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 WOODWINDS DR
WOODBURY MN
55125-2522
US

IV. Provider business mailing address

2040 WOODWINDS DR
WOODBURY MN
55125-2522
US

V. Phone/Fax

Practice location:
  • Phone: 651-259-9750
  • Fax: 651-259-9790
Mailing address:
  • Phone: 651-259-9750
  • Fax: 651-259-9790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number38890
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: