Provider Demographics
NPI:1376187120
Name:KENNEDY, HEATHER ANN (RDN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ANN
Other - Last Name:PUCKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 N DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-1049
Mailing Address - Country:US
Mailing Address - Phone:608-768-6243
Mailing Address - Fax:
Practice Address - Street 1:2000 N DEWEY AVE
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-1049
Practice Address - Country:US
Practice Address - Phone:608-768-6243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2750-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered