Provider Demographics
NPI:1578570743
Name:KENNEDY, LISA SHEA (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:SHEA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 EVERGREEN WAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-2619
Mailing Address - Country:US
Mailing Address - Phone:425-382-4000
Mailing Address - Fax:
Practice Address - Street 1:8609 EVERGREEN WAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-2619
Practice Address - Country:US
Practice Address - Phone:425-382-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101039112207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA320601OtherANTHEM PROVIDER #
VA320602OtherANTHEM HEALTHKEEPERS #
VA4107755OtherAETNA PROVIDER #
VA5624959Medicaid
VA320602OtherANTHEM HEALTHKEEPERS #
VAC36719Medicare UPIN