Provider Demographics
NPI:1679782395
Name:KENNEDY, NICOLE A (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:A
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:6777 W MAPLE RD
Mailing Address - Street 2:DEPARTMENT OF VASCULAR SURGERY
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3013
Mailing Address - Country:US
Mailing Address - Phone:248-325-3087
Mailing Address - Fax:248-325-0071
Practice Address - Street 1:6777 W MAPLE RD
Practice Address - Street 2:DEPARTMENT OF VASCULAR SURGERY
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3013
Practice Address - Country:US
Practice Address - Phone:248-325-3087
Practice Address - Fax:248-325-0071
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2013-04-26
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Provider Licenses
StateLicense IDTaxonomies
MI4301081948208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery