MEDICARE: LISA A KENNEDY, RD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DT07616	TX

General Provider Information

NPI Number	:	1861973091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA A KENNEDY, RD LLC

Provider Business Mailing Address
First Line	:	PO BOX 538
Second Line	:
City	:	ETOILE
State	:	TX
Zip	:	75944-0538
Country	:	US
Telephone Number	:	936-628-9123
Fax Number	:

Provider Business Practice Location Address
First Line	:	4635 NE STALLINGS DR STE 104
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-1667
Country	:	US
Telephone Number	:	936-628-9123
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	LISA A KENNEDY
Credential	:	RD
Telephone Number	:	936-628-9123

Provider Enumeration Date	:	08/26/2018
Last Update Date	:	08/26/2018

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