Provider Demographics
NPI:1114953353
Name:KENNEDY, KYLE LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:LEE
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5211 W 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-4120
Mailing Address - Country:US
Mailing Address - Phone:806-355-8293
Mailing Address - Fax:806-355-7298
Practice Address - Street 1:5211 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-4120
Practice Address - Country:US
Practice Address - Phone:806-355-8293
Practice Address - Fax:806-355-7298
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0325174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG95558Medicare UPIN