Provider Demographics
NPI:1194222844
Name:KENNEDY, KELSEY REAL
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:REAL
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:CAITLIN
Other - Last Name:REAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:48 MEDICAL PARK DR E STE 458
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3473
Mailing Address - Country:US
Mailing Address - Phone:205-838-1811
Mailing Address - Fax:
Practice Address - Street 1:48 MEDICAL PARK DR E STE 458
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3473
Practice Address - Country:US
Practice Address - Phone:205-838-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC238687207R00000X
GA10959207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine