Provider Demographics
NPI:1043550833
Name:KENNEDY, KIM MARIE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W8500 BREEZY POINT RD
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-9265
Mailing Address - Country:US
Mailing Address - Phone:920-382-9958
Mailing Address - Fax:
Practice Address - Street 1:W8500 BREEZY POINT RD
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-9265
Practice Address - Country:US
Practice Address - Phone:920-382-9958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI142248163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse