Provider Demographics
NPI:1912551441
Name:KENNEDY, STEPHANIE M
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 SOUTH BLVD E STE 200
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-6116
Mailing Address - Country:US
Mailing Address - Phone:248-997-5805
Mailing Address - Fax:248-997-5811
Practice Address - Street 1:1701 SOUTH BLVD E STE 200
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-6116
Practice Address - Country:US
Practice Address - Phone:248-997-5805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704306510207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology