Provider Demographics
NPI:1831120153
Name:KENNEDY, REBECCA DAWN (OD)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:DAWN
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 1:5773 GREENBACK LANE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841
Mailing Address - Country:US
Mailing Address - Phone:916-863-3143
Mailing Address - Fax:916-863-3143
Practice Address - Street 1:7900 ZENITH DR
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-1075
Practice Address - Country:US
Practice Address - Phone:916-725-2020
Practice Address - Fax:916-725-1750
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12401152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU95324Medicare UPIN
CASD0124010Medicare ID - Type Unspecified