Provider Demographics
NPI:1578677068
Name:KENNON, JULIE RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:RENEE
Last Name:KENNON
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:PO BOX 636493
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6493
Mailing Address - Country:US
Mailing Address - Phone:513-981-5130
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:749 IRVINE RD
Practice Address - Street 2:
Practice Address - City:CLAY CITY
Practice Address - State:KY
Practice Address - Zip Code:40312-9732
Practice Address - Country:US
Practice Address - Phone:606-663-2153
Practice Address - Fax:606-663-7966
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33379207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64007891Medicaid
KY607850200OtherFEDERAL BLACK LUNG
KY607850200OtherFEDERAL BLACK LUNG
KYK039930Medicare PIN