Provider Demographics
NPI:1821226499
Name:KENNEDY, HEATHER AINE (DO)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:AINE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-1618
Mailing Address - Country:US
Mailing Address - Phone:920-623-9611
Mailing Address - Fax:920-623-1788
Practice Address - Street 1:1513 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1618
Practice Address - Country:US
Practice Address - Phone:920-623-9611
Practice Address - Fax:920-623-1788
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI58094-21207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1821226499Medicaid
WIP01479433Medicare PIN
WIK400176211Medicare PIN
WIP01367497Medicare PIN