Provider Demographics
NPI:1578570743
Name:KENNEDY, LISA SHEA (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:SHEA
Last Name:KENNEDY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 POWELL AVE SW
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2908
Mailing Address - Country:US
Mailing Address - Phone:425-277-1311
Mailing Address - Fax:425-277-1566
Practice Address - Street 1:403 E MEEKER ST STE 200
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-5904
Practice Address - Country:US
Practice Address - Phone:253-852-2866
Practice Address - Fax:253-852-3102
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101039112207Q00000X
WAMD60952683207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA320602OtherANTHEM HEALTHKEEPERS #
VA320601OtherANTHEM PROVIDER #
VA4107755OtherAETNA PROVIDER #
VA5624959Medicaid
VA320602OtherANTHEM HEALTHKEEPERS #
VAC36719Medicare UPIN