Provider Demographics
NPI:1619016789
Name:KENNEDY, AMY (OD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 LONG ST
Mailing Address - Street 2:P.O. BOX 256
Mailing Address - City:ASHVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43103-1333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:317 LONG ST
Practice Address - Street 2:
Practice Address - City:ASHVILLE
Practice Address - State:OH
Practice Address - Zip Code:43103-1333
Practice Address - Country:US
Practice Address - Phone:740-983-6171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4754152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2507022Medicaid
U68930Medicare UPIN
OH2507022Medicaid