Provider Demographics
NPI:1124559844
Name:KENNEDY, KAITLYN (MD)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:MULHERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:MSC 11 6025
Mailing Address - Street 2:1 UNIVERSITY OF NEW MEXICO
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MSC 11 6025
Practice Address - Street 2:1 UNIVERSITY OF NEW MEXICO
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-5062
Practice Address - Fax:505-272-6503
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
WAMD61055965207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program