Provider Demographics
NPI:1407896962
Name:KENNEDY, DENISE A (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:A
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DOROTHY DENISE
Other - Middle Name:ABBOTT
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:200 E WASHINGTON ST
Mailing Address - Street 2:P O BOX 8031
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5490
Mailing Address - Country:US
Mailing Address - Phone:800-236-1489
Mailing Address - Fax:920-739-0124
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36609-20207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32121400Medicaid
G06007Medicare UPIN
WI0009 07199Medicare ID - Type UnspecifiedMEDICARE PROVIDER #