Provider Demographics
NPI:1871014969
Name:KENNEDY, KATHERINE GREER (OD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:GREER
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:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-0012
Mailing Address - Country:US
Mailing Address - Phone:256-878-3024
Mailing Address - Fax:
Practice Address - Street 1:390 GUNTER AVE
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976
Practice Address - Country:US
Practice Address - Phone:256-878-3024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-D81-TA-A86152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL191288Medicaid