Provider Demographics
NPI:1083618409
Name:KENNEDY, SHEILA Z (DO)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:Z
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 HARVEY RD
Mailing Address - Street 2:STE E
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-4247
Mailing Address - Country:US
Mailing Address - Phone:253-939-1066
Mailing Address - Fax:253-939-1069
Practice Address - Street 1:820 HARVEY RD
Practice Address - Street 2:STE E
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4247
Practice Address - Country:US
Practice Address - Phone:253-939-1066
Practice Address - Fax:253-939-1069
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1019082Medicaid
G8873900Medicare PIN
WAE23498Medicare UPIN