Provider Demographics
NPI:1275550840
Name:KENNEDY, CASSANDRA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:CASSANDRA
Middle Name:ANN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 RENNER DR
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-3120
Mailing Address - Country:US
Mailing Address - Phone:707-725-9832
Mailing Address - Fax:707-725-7247
Practice Address - Street 1:3300 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3120
Practice Address - Country:US
Practice Address - Phone:707-725-9832
Practice Address - Fax:707-725-7247
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79397208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G793970Medicaid
CA00G793970Medicare ID - Type Unspecified
CA00G793970Medicaid
CAG71421Medicare UPIN