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General NPI Number Information
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NPI Number | 1821226499
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Entity Type | Individual
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Provider Name | HEATHER AINE KENNEDY D.O.
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Gender | Female
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Dates
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Enumeration Date | 06/23/2009
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Last Update Date | 09/06/2024
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Provider Practice Location Address
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Address Line | 1211 CORTINA DR
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City | ORLAND
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State | CA
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Zip | 95963-1699
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Country | US
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Telephone | 530-865-5544
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Fax | 530-865-9209
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Provider Business Mailing Address
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Address Line | 1513 PARK AVE
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City | COLUMBUS
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State | WI
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Zip | 53925-1618
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Country | US
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Telephone | 920-623-9611
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Fax | 920-623-1788
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 58094-21
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License Number State | WI
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