Provider Demographics
NPI:1326136359
Name:KENNEDY, DEBORAH ANN (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:ANN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N 5TH ST
Mailing Address - Street 2:PO BOX 877
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-2010
Mailing Address - Country:US
Mailing Address - Phone:936-544-3438
Mailing Address - Fax:936-544-8126
Practice Address - Street 1:120 N 5TH ST
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-2010
Practice Address - Country:US
Practice Address - Phone:936-544-3438
Practice Address - Fax:936-544-8126
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT00538133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA752442768 8359BOMedicare ID - Type Unspecified
TXA752442768 0168TMedicare ID - Type UnspecifiedMADISON ST. JOSEPH GROUP