Provider Demographics
NPI:1609329671
Name:KENNEDY, AUDRA (MD)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
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 1:820 MONTGOMERY RD STE 202
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:TX
Mailing Address - Zip Code:76450-4200
Mailing Address - Country:US
Mailing Address - Phone:940-549-7741
Mailing Address - Fax:855-615-3435
Practice Address - Street 1:820 MONTGOMERY RD STE 202
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:TX
Practice Address - Zip Code:76450-4200
Practice Address - Country:US
Practice Address - Phone:940-549-7741
Practice Address - Fax:855-615-3435
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS4508207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470553011-00Medicaid