Healthcare Provider Details

I. General information

NPI: 1659058477
Provider Name (Legal Business Name): KALLEAN J KENNEDY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 SUNSET BLVD
WEST COLUMBIA SC
29169-4810
US

IV. Provider business mailing address

PO BOX 739949
DALLAS TX
75373-9949
US

V. Phone/Fax

Practice location:
  • Phone: 803-791-2350
  • Fax: 803-791-2520
Mailing address:
  • Phone: 803-791-2350
  • Fax: 803-791-2520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberT-4947
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number97289
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: