Provider Demographics
NPI:1336496298
Name:KENNEDY, KRISTINA (OD)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
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 1:1727 HUMBOLDT ST
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-4140
Mailing Address - Country:US
Mailing Address - Phone:913-963-3616
Mailing Address - Fax:
Practice Address - Street 1:809 N 3RD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-5703
Practice Address - Country:US
Practice Address - Phone:785-537-2020
Practice Address - Fax:844-537-2020
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1937152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist