Provider Demographics
NPI:1154480911
Name:KENNEDY, CHRISTINA TAN MICHELLE (OD)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:TAN MICHELLE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3060 FRANKLIN TER
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4123
Mailing Address - Country:US
Mailing Address - Phone:423-282-4221
Mailing Address - Fax:423-282-5124
Practice Address - Street 1:6709 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6209
Practice Address - Country:US
Practice Address - Phone:260-432-8409
Practice Address - Fax:260-484-0616
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002409152W00000X
MI4901004315152W00000X
TN2916152W00000X
IN18003936AB152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist