Healthcare Provider Details

I. General information

NPI: 1053429159
Provider Name (Legal Business Name): DIANA L. KENNEDY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 MCAULEY BLVD SUITE 420
OKLAHOMA CITY OK
73120-8347
US

IV. Provider business mailing address

4205 MCAULEY BLVD SUITE 420
OKLAHOMA CITY OK
73120-8347
US

V. Phone/Fax

Practice location:
  • Phone: 405-751-6111
  • Fax: 405-751-0479
Mailing address:
  • Phone: 405-751-6111
  • Fax: 405-751-0479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number13883
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: