Provider Demographics
NPI:1992191662
Name:KENNEDY, TARA (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W180N8000 TOWN HALL RD
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-4002
Mailing Address - Country:US
Mailing Address - Phone:262-532-3700
Mailing Address - Fax:262-532-3725
Practice Address - Street 1:W180N8000 TOWN HALL RD
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-4002
Practice Address - Country:US
Practice Address - Phone:262-532-3700
Practice Address - Fax:262-532-3725
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69210-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1992191662Medicaid