Provider Demographics
NPI:1790011062
Name:KENNESON, MARYANN (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARYANN
Middle Name:
Last Name:KENNESON
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 1:10881 SAN JOSE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-6612
Mailing Address - Country:US
Mailing Address - Phone:904-260-3022
Mailing Address - Fax:904-260-3947
Practice Address - Street 1:1895 KINGSLEY AVE STE 903
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4410
Practice Address - Country:US
Practice Address - Phone:904-644-8353
Practice Address - Fax:904-644-8289
Is Sole Proprietor?:No
Enumeration Date:2009-10-21
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35098042208800000X
FLME92864208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0056336Medicaid
FL14N6LOtherBCBS
FL006734700Medicaid
FL006734700Medicaid
OH0056336Medicaid
FL006734700Medicaid