Provider Demographics
NPI:1932135019
Name:KENNEDY, STEPHANIE M (CRNA)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:M
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:ML 5021
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-0356
Mailing Address - Fax:513-636-2511
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML 5021
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-0356
Practice Address - Fax:513-636-2511
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN286357367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2543966Medicaid
KY74009689Medicaid
KY74009689Medicaid