Provider Demographics
NPI:1508921685
Name:KENNEDY, NANCY J (OD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:J
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 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:700 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5115
Practice Address - Country:US
Practice Address - Phone:360-923-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001331152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8100521Medicaid
WAGAB18941Medicare PIN
WAGAB18940Medicare PIN
WAGAB18944Medicare PIN
WAGAB18943Medicare PIN
WAGAB18942Medicare PIN
WAG8872403Medicare PIN