Provider Demographics
NPI:1568571115
Name:KENNEDY, THERESA PAIGE (OD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:PAIGE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6945 HIGHWAY 72 W
Mailing Address - Street 2:STE G
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35806-1789
Mailing Address - Country:US
Mailing Address - Phone:256-325-6950
Mailing Address - Fax:256-585-1019
Practice Address - Street 1:8089 HIGHWAY 72 W
Practice Address - Street 2:SUITE A
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-9530
Practice Address - Country:US
Practice Address - Phone:256-325-9465
Practice Address - Fax:256-325-9467
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-850-TA-354152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051554421Medicare PIN
ALU70726Medicare UPIN