Provider Demographics
NPI:1164139523
Name:KENNEDY, STACIA ANN (IBCLC)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:ANN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7912 S 183RD ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68136-6438
Mailing Address - Country:US
Mailing Address - Phone:402-651-3776
Mailing Address - Fax:
Practice Address - Street 1:7912 S 183RD ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68136-6438
Practice Address - Country:US
Practice Address - Phone:402-651-3776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE74873163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant