Provider Demographics
NPI:1407822265
Name:KENNEDY, LISA A (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
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:PO BOX 43366
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35243-0366
Mailing Address - Country:US
Mailing Address - Phone:205-995-2020
Mailing Address - Fax:205-991-9654
Practice Address - Street 1:4515 SOUTHLAKE PKWY
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35244-3317
Practice Address - Country:US
Practice Address - Phone:205-987-2020
Practice Address - Fax:205-988-0588
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-987-TA-572152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALS-987-TA-572OtherAL BOARD OF OPTOMETRY
ALS-987-TA-572OtherAL BOARD OF OPTOMETRY
ALU90376Medicare UPIN