Provider Demographics
NPI:1821190679
Name:KENNEDY, COLLEEN A (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:A
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 1:3301 WOODBURN RD #208
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-1200
Mailing Address - Country:US
Mailing Address - Phone:703-560-9495
Mailing Address - Fax:703-698-7237
Practice Address - Street 1:3301 WOODBURN RD #208
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-1200
Practice Address - Country:US
Practice Address - Phone:703-560-9495
Practice Address - Fax:703-698-7237
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
00B308F50Medicare ID - Type Unspecified
B98901Medicare UPIN