Provider Demographics
NPI:1568758100
Name:KENNEDY-ETO, KAUAI NICOLE (M,D, MPH)
Entity Type:Individual
Prefix:
First Name:KAUAI
Middle Name:NICOLE
Last Name:KENNEDY-ETO
Suffix:
Gender:F
Credentials:M,D, MPH
Other - Prefix:
Other - First Name:KAUAI
Other - Middle Name:NICOLE
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1711 N. ORANGE STREET
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-2254
Mailing Address - Country:US
Mailing Address - Phone:909-792-2200
Mailing Address - Fax:909-792-2660
Practice Address - Street 1:1711 N. ORANGE STREET
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2254
Practice Address - Country:US
Practice Address - Phone:909-792-2200
Practice Address - Fax:909-792-2660
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA127206207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology