Provider Demographics
NPI:1497198600
Name:KENNEDY, JOHN EDWARD III (RN)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EDWARD
Last Name:KENNEDY
Suffix:III
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-5543
Mailing Address - Country:US
Mailing Address - Phone:715-571-1343
Mailing Address - Fax:
Practice Address - Street 1:210 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-5543
Practice Address - Country:US
Practice Address - Phone:715-845-3637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI193347-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse