Provider Demographics
NPI:1346409612
Name:KENNEMER, KIRSTEN RENEE (AUD)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:RENEE
Last Name:KENNEMER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7749 NORTHUMBERLAND DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-2171
Mailing Address - Country:US
Mailing Address - Phone:214-850-4958
Mailing Address - Fax:
Practice Address - Street 1:901 HEMPHILL
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-332-4060
Practice Address - Fax:817-332-2304
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80126231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00693131OtherRAILROAD MEDICARE
TX200463201Medicaid