Healthcare Provider Details

I. General information

NPI: 1649665563
Provider Name (Legal Business Name): KENNA SHEAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE
CINCINNATI OH
45229
US

IV. Provider business mailing address

3333 BURNET AVE ML 9016
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4225
  • Fax:
Mailing address:
  • Phone: 513-803-8092
  • Fax: 513-803-9245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2018-0246
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: